Basic Information
Provider Information | |||||||||
NPI: | 1346869419 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ACCESS MEDICAL CLINIC ARKANSAS LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4196 HIGHWAY 62 412 STE A | ||||||||
Address2: |   | ||||||||
City: | HARDY | ||||||||
State: | AR | ||||||||
PostalCode: | 725428002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 9798 HIGHWAY 62 W | ||||||||
Address2: |   | ||||||||
City: | VIOLA | ||||||||
State: | AR | ||||||||
PostalCode: | 725836001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8704586732 | ||||||||
FaxNumber: | 8708952164 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/09/2020 | ||||||||
LastUpdateDate: | 12/11/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | YORK | ||||||||
AuthorizedOfficialFirstName: | MONYA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATIVE CREDENTIALING | ||||||||
AuthorizedOfficialTelephone: | 8708561202 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/11/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 261QR1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.