=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740317452
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAWRENCE COUNTY FAMILY CLINIC, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2007
-----------------------------------------------------
Last Update Date | 05/15/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1210 W MAIN ST
-----------------------------------------------------
City | WALNUT RIDGE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72476-1005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-886-3543
-----------------------------------------------------
Fax | 870-886-3252
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 719
-----------------------------------------------------
City | WALNUT RIDGE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72476-0719
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-886-3543
-----------------------------------------------------
Fax | 870-886-3252
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | INSURANCE CLERK
-----------------------------------------------------
Name | MRS. ANITA B MARLIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 870-886-3543
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------