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General NPI Number Information
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NPI Number | 1619516200
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Entity Type | Organization
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Legal Business Name | BAXTER REGIONAL HEALTH SYSTEM
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Dates
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Enumeration Date | 12/30/2019
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Last Update Date | 12/30/2019
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Provider Practice Location Address
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Address Line | 277 MAIN STREET
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City | MAMMOTH SPRING
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State | AR
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Zip | 72554
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Country | US
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Telephone | 870-269-3455
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1288
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City | MOUNTAIN VIEW
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State | AR
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Zip | 72560-1288
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | VICE PRESIDENT
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Name | LEONARD BERNARD LARRY
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Credential |
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Telephone | 870-508-1011
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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