MEDICARE: BACK TO HEALTH MEDICAL CLINIC

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	261QP2300X	Primary Care Clinic/Center	N-7372	AR

General Provider Information

NPI Number	:	1548325160
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BACK TO HEALTH MEDICAL CLINIC

Provider Business Mailing Address
First Line	:	6800 S. DALLAS ST
Second Line	:	STE A
City	:	FT. SMITH
State	:	AR
Zip	:	72903-5189
Country	:	US
Telephone Number	:	479-484-7575
Fax Number	:

Provider Business Practice Location Address
First Line	:	6800 S. DALLAS ST
Second Line	:	STE A
City	:	FT. SMITH
State	:	AR
Zip	:	72903-5189
Country	:	US
Telephone Number	:	479-484-7575
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SAMUEL W. PRICE SR.
Credential	:	D.O.
Telephone Number	:	479-484-7575

Provider Enumeration Date	:	12/26/2006
Last Update Date	:	08/22/2020

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