MEDICARE: OZARK LASER AND SURGERY CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center	MC 2363	AR

General Provider Information

NPI Number	:	1093710220
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OZARK LASER AND SURGERY CENTER

Provider Business Mailing Address
First Line	:	2070 MCKENZIE RD
Second Line	:	STE B
City	:	SPRINGDALE
State	:	AR
Zip	:	72762-0747
Country	:	US
Telephone Number	:	479-751-4743
Fax Number	:	479-751-1345

Provider Business Practice Location Address
First Line	:	2070 MCKENZIE RD
Second Line	:	STE B
City	:	SPRINGDALE
State	:	AR
Zip	:	72762-0747
Country	:	US
Telephone Number	:	479-751-4743
Fax Number	:	479-751-1345

Authorized Official
Title or Position	:	OWNER/OPERATOR
Name	:	MR. JOHN A BILIINGSLEY III
Credential	:	M.D.
Telephone Number	:	479-751-4743

Provider Enumeration Date	:	06/15/2005
Last Update Date	:	08/22/2020

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