Basic Information
Provider Information | |||||||||
NPI: | 1407819840 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ST.BERNARDS PET CENTER LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 9178 | ||||||||
Address2: |   | ||||||||
City: | RUSSELLVILLE | ||||||||
State: | AR | ||||||||
PostalCode: | 728119178 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4799687930 | ||||||||
FaxNumber: | 4799681673 | ||||||||
Practice Location | |||||||||
Address1: | 225 E JACKSON AVE | ||||||||
Address2: |   | ||||||||
City: | JONESBORO | ||||||||
State: | AR | ||||||||
PostalCode: | 724013119 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8772233988 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/07/2006 | ||||||||
LastUpdateDate: | 12/17/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | THOMASON | ||||||||
AuthorizedOfficialFirstName: | RODNEY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
AuthorizedOfficialTelephone: | 4799687930 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
ID | Type | State | Issuer | Description | 5C658 | 01 | AR | BCBS PROVIDER NUMBER | OTHER | 146893002 | 05 | AR |   | MEDICAID |