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General NPI Number Information
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NPI Number | 1417123258
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Entity Type | Organization
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Legal Business Name | DEPARTMENT OF VETERANS AFFAIRS
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Dates
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Enumeration Date | 05/01/2008
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Last Update Date | 05/01/2008
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Provider Practice Location Address
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Address Line | 910 REALTOR AVENUE
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City | TEXARKANA
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State | AR
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Zip | 71854-5066
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Country | US
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Telephone | 870-824-4181
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Fax |
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Provider Business Mailing Address
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Address Line | 1107 LOCUST ST
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City | TEXARKANA
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State | AR
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Zip | 71854-5066
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Country | US
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Telephone | 903-824-4181
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Fax |
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Authorized Official
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Title or Position | STAFF NURSE
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Name | MR. TIMOTHY D. GREATHOUSE
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Credential | L.P.N.
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Telephone | 870-216-2512
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QF0400X
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Taxonomy Name | Federally Qualified Health Center (FQHC)
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License Number | L29493
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License Number State | AR
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