Basic Information
Provider Information | |||||||||
NPI: | 1104088632 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DIERKSEN OF TEXARKANA ARKANSAS LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | DIERKSEN MEMORIAL HOSPICE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 500 FAULCONER DR STE 200 | ||||||||
Address2: |   | ||||||||
City: | CHARLOTTESVILLE | ||||||||
State: | VA | ||||||||
PostalCode: | 229035089 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4349779711 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4613 PARKWAY DR STE 20 | ||||||||
Address2: |   | ||||||||
City: | TEXARKANA | ||||||||
State: | AR | ||||||||
PostalCode: | 71854 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8707734353 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/26/2008 | ||||||||
LastUpdateDate: | 01/09/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HUNTER | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
AuthorizedOfficialTelephone: | 4349779711 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/09/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | AR 4279 | AR | Y |   | Agencies | Hospice Care, Community Based |   |
No ID Information.