=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457353914
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LITTLE RIVER MEMORIAL HOSPITAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/15/2005
-----------------------------------------------------
Last Update Date | 05/03/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 451 W LOCKE ST
-----------------------------------------------------
City | ASHDOWN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71822-3325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-898-5011
-----------------------------------------------------
Fax | 870-898-4172
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 451 W LOCKE ST
-----------------------------------------------------
City | ASHDOWN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71822-3325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-898-5011
-----------------------------------------------------
Fax | 870-898-4172
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. DAVID DEATON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 870-898-5011
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | AR4204
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------