=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669742011
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SAMUEL B. HESTER PHD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/03/2012
-----------------------------------------------------
Last Update Date | 01/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 361 SOUTHWEST DR # 105
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72401-5854
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-219-1407
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 361 SOUTHWEST DR # 105
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72401-5854
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-219-1407
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. SAMUEL BROUD HESTER
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 870-219-1407
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number | 81-4P
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------