Basic Information
| Provider Information | |||||||||
| NPI: | 1386944791 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHWEST ARKANSAS IMMUNIZATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9178 | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728119178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4799684273 | ||||||||
| FaxNumber: | 4799681363 | ||||||||
| Practice Location | |||||||||
| Address1: | 2719 SE I ST | ||||||||
| Address2: | |||||||||
| City: | BENTONVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727123996 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4792735437 | ||||||||
| FaxNumber: | 4792739932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2010 | ||||||||
| LastUpdateDate: | 11/09/2010 | ||||||||
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| AuthorizedOfficialLastName: | CADLE | ||||||||
| AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIA-OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4792735437 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.