Basic Information
| Provider Information | |||||||||
| NPI: | 1588618292 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WASHINGTON REGIONAL MEDICAL SYSTEM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WASHINGTON REGIONAL SENIOR CLINIC B | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 879 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727020879 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797137115 | ||||||||
| FaxNumber: | 4797137186 | ||||||||
| Practice Location | |||||||||
| Address1: | 3211 N NORTH HILLS BLVD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794634444 | ||||||||
| FaxNumber: | 4794634499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ROTHROCK | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | JO | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR CLINIC ADMINISTRATION | ||||||||
| AuthorizedOfficialTelephone: | 4794631390 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health |
No ID Information.