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General NPI Number Information
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NPI Number | 1639163363
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Entity Type | Organization
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Legal Business Name | SPANISH TRACE CLINIC
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Dates
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Enumeration Date | 09/08/2005
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 1205 E 35TH ST
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City | TEXARKANA
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State | AR
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Zip | 71854-2746
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Country | US
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Telephone | 903-735-5355
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Fax | 903-735-5399
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Provider Business Mailing Address
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Address Line | PO BOX 811
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City | TEXARKANA
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State | TX
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Zip | 75504-0811
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Country | US
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Telephone | 903-735-5355
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Fax | 903-735-5399
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Authorized Official
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Title or Position | PROVIDER
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Name | DR. JERRY B SRTINGFELLOW
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Credential | MD
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Telephone | 903-735-5355
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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 | AR
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