Basic Information
| Provider Information | |||||||||
| NPI: | 1205280138 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL ARKANSAS SPINE SPECIALIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1615 | ||||||||
| Address2: | |||||||||
| City: | SEARCY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721451615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5017766252 | ||||||||
| FaxNumber: | 5017766271 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 MEDICAL PARK DR | ||||||||
| Address2: | STE 308 | ||||||||
| City: | BENTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720153729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5017766545 | ||||||||
| FaxNumber: | 5017766546 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2016 | ||||||||
| LastUpdateDate: | 04/18/2016 | ||||||||
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| AuthorizedOfficialLastName: | KIPP | ||||||||
| AuthorizedOfficialFirstName: | ANNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5017766039 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SALINE PHYSICIAN SERVICES | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | AR | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.