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General NPI Number Information
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NPI Number | 1639561103
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Entity Type | Organization
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Legal Business Name | N/A
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Dates
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Enumeration Date | 02/20/2015
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Last Update Date | 02/20/2015
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Provider Practice Location Address
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Address Line | 6814 PRINCETON PIKE
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City | PINE BLUFF
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State | AR
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Zip | 71602-9411
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Country | US
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Telephone | 501-353-3765
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 13585
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City | MAUMELLE
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State | AR
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Zip | 72113-0585
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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 | PHYSICIAN
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Name | DR. SHAWN MICHAEL RICHARD
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Credential | MD
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Telephone | 501-803-3418
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 273R00000X
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Taxonomy Name | Psychiatric Hospital Unit
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License Number | 022748
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License Number State | LA
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Taxonomy #2
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Taxonomy Code | 273R00000X
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Taxonomy Name | Psychiatric Hospital Unit
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License Number | E-5344
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License Number State | AR
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