Basic Information
| Provider Information | |||||||||
| NPI: | 1568471571 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ARKANSAS RURAL KARE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MOUNTAINBURG FAMILY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 310 TOWSON AVE | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729013831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794940009 | ||||||||
| FaxNumber: | 4794940005 | ||||||||
| Practice Location | |||||||||
| Address1: | #4 HWY 71 NE | ||||||||
| Address2: | |||||||||
| City: | MOUNTAINBURG | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4793692091 | ||||||||
| FaxNumber: | 4793694119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2006 | ||||||||
| LastUpdateDate: | 02/25/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KING | ||||||||
| AuthorizedOfficialFirstName: | WAYNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4794940009 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 770245002 | 01 | AR | ARKANSAS BREASTCARE | OTHER |