=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689569352
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BREEDLOVE WOUND CARE OF ARKANSAS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2025
-----------------------------------------------------
Last Update Date | 06/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1415 N SAINT LOUIS
-----------------------------------------------------
City | BATESVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72501-8467
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-947-2020
-----------------------------------------------------
Fax | 903-352-3665
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1129
-----------------------------------------------------
City | TATUM
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75691-1129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-947-2020
-----------------------------------------------------
Fax | 903-352-3665
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ELIZABETH ANN BREEDLOVE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 903-947-2020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------