=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649237165
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARK-LA-TEX HEALTH CENTER PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/27/2006
-----------------------------------------------------
Last Update Date | 10/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1414 ARKANSAS BLVD
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71854-1604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-773-7246
-----------------------------------------------------
Fax | 870-772-2568
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1414 ARKANSAS BLVD
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71854-1604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-773-7246
-----------------------------------------------------
Fax | 870-772-2568
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JAMES D RAKER
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 870-773-7246
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1141
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | A01334
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | AO3679
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | N8393
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------