Basic Information
| Provider Information | |||||||||
| NPI: | 1104356419 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DE QUEEN MEDICAL CENTER DIALYSIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1306 W COLLIN RAYE DR | ||||||||
| Address2: | |||||||||
| City: | DE QUEEN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 718322502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705844111 | ||||||||
| FaxNumber: | 8705844100 | ||||||||
| Practice Location | |||||||||
| Address1: | 1306 W COLLIN RAYE DR | ||||||||
| Address2: | |||||||||
| City: | DE QUEEN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 718322502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705844111 | ||||||||
| FaxNumber: | 8705844100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | ICENHOWER | ||||||||
| AuthorizedOfficialFirstName: | JERRAMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8705840272 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DE QUEEN MEDICAL CENTER, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.