=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508675612
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARLYLE CARE CLINIC, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2025
-----------------------------------------------------
Last Update Date | 01/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 509 E MILLSAP RD STE 107
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72703-4862
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-480-7150
-----------------------------------------------------
Fax | 479-968-1673
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 9178
-----------------------------------------------------
City | RUSSELLVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72811-9178
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-824-4094
-----------------------------------------------------
Fax | 479-968-1673
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | BENJAMIN WAGNER CARLYLE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 479-498-6700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------