Basic Information
| Provider Information | |||||||||
| NPI: | 1477813012 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TBA TEXARKANA LLC | ||||||||
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| OtherOrganizationName: | VISTA HEALTH TEXARKANA (PRESCOTT GRP) | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3352 N FUTRALL DR | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727034057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4795211427 | ||||||||
| FaxNumber: | 4795216520 | ||||||||
| Practice Location | |||||||||
| Address1: | 1484 W 1ST ST N | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AR | ||||||||
| PostalCode: | 718573339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708871078 | ||||||||
| FaxNumber: | 8708870281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2012 | ||||||||
| LastUpdateDate: | 05/16/2012 | ||||||||
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| AuthorizedOfficialLastName: | NAPLES | ||||||||
| AuthorizedOfficialFirstName: | KYLE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4795211427 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | AMICARE BEHAVIORAL CENTERS LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.