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General NPI Number Information
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NPI Number | 1700211885
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Entity Type | Organization
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Legal Business Name | FORT SMITH NEUROSCIENCE CENTER, PLLC.
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Dates
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Enumeration Date | 09/09/2013
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Last Update Date | 12/03/2014
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Provider Practice Location Address
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Address Line | 7217 CAMERON PARK DRIVE
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City | FORT SMITH
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State | AR
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Zip | 72903
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Country | US
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Telephone | 479-434-3544
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Fax | 479-434-3547
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Provider Business Mailing Address
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Address Line | PO BOX 180969
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City | FORT SMITH
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State | AR
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Zip | 72918-0969
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Country | US
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Telephone | 479-434-3544
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Fax | 479-434-3547
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Authorized Official
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Title or Position | OWNER
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Name | SHAWN P MOORE
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Credential | M.D.
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Telephone | 479-434-3544
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | E6954
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License Number State | AR
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