=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629030358
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIGESTIVE CARE P A
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2006
-----------------------------------------------------
Last Update Date | 09/14/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4800 S HAZEL ST
-----------------------------------------------------
City | PINE BLUFF
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71603-6860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-534-5533
-----------------------------------------------------
Fax | 870-534-5535
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2797
-----------------------------------------------------
City | PINE BLUFF
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71613-2797
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-534-5533
-----------------------------------------------------
Fax | 870-534-5535
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. FRANCES STUCKS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 870-534-5533
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------