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General NPI Number Information
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NPI Number | 1710934542
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Entity Type | Organization
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Legal Business Name | JEFFERSON SURGERY CENTER PLLC
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Dates
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Enumeration Date | 05/27/2006
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Last Update Date | 08/26/2008
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Provider Practice Location Address
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Address Line | 1609 W 40TH AVE JRMC PROFESSIONAL CENTER, SUITE 103
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City | PINE BLUFF
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State | AR
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Zip | 71603-6329
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Country | US
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Telephone | 870-541-3636
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Fax | 870-541-3639
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Provider Business Mailing Address
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Address Line | 1609 W 40TH AVE JRMC PROFESSIONAL CENTER, SUITE 103
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City | PINE BLUFF
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State | AR
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Zip | 71603-6329
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Country | US
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Telephone | 870-541-3636
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Fax | 870-541-3639
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MRS. CRYSTAL R BOHANNAN
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Credential | CPA
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Telephone | 870-541-3640
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | AR3637
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License Number State | AR
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