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General NPI Number Information
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NPI Number | 1629252440
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Entity Type | Organization
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Legal Business Name | SOVEREIGN FORCE, PA
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Dates
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Enumeration Date | 12/28/2007
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Last Update Date | 12/28/2007
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Provider Practice Location Address
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Address Line | 301 SW 16TH ST
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City | BENTONVILLE
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State | AR
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Zip | 72712-7173
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Country | US
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Telephone | 479-586-9800
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Fax |
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Provider Business Mailing Address
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Address Line | 301 SW 16TH ST
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City | BENTONVILLE
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State | AR
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Zip | 72712-7173
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Country | US
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Telephone | 479-586-9800
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. AJDAHAN D. BICAK
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Credential | M.D.
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Telephone | 479-586-9800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | MC-2586
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License Number State | AR
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