=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396102679
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIVING TREE PEDIATRICS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2016
-----------------------------------------------------
Last Update Date | 03/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1110 SE 30TH STREET
-----------------------------------------------------
City | BENTONVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72712-4290
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-282-2966
-----------------------------------------------------
Fax | 479-282-2967
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 2760
-----------------------------------------------------
City | BENTONVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72712-4290
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-282-2966
-----------------------------------------------------
Fax | 479-282-2967
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | MRS. JULIE LYNETTE TATE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 479-282-2966
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | E7529
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------