=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871622621
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DOC'S CLINIC AND INSTITUTE, PLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/05/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4220 N CROSSOVER RD
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72703-4593
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-251-1552
-----------------------------------------------------
Fax | 479-251-8956
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4220 N CROSSOVER RD
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72703-4593
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-251-1552
-----------------------------------------------------
Fax | 479-251-8956
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FAMILY PRACTICE PHYSICIAN
-----------------------------------------------------
Name | RANDALL BENJAMIN OATES
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 479-251-1552
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | C-5922
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------