Basic Information
Provider Information | |||||||||
NPI: | 1609084268 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CRITTENDEN HOSPITAL ASSOCIATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CRITTENDEN REGIONAL HOSPITAL HOME HEALTH-MARKED TREE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 48 FRISCO ST | ||||||||
Address2: |   | ||||||||
City: | MARKED TREE | ||||||||
State: | AR | ||||||||
PostalCode: | 723652214 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8703584018 | ||||||||
FaxNumber: | 8703584027 | ||||||||
Practice Location | |||||||||
Address1: | 48 FRISCO ST | ||||||||
Address2: |   | ||||||||
City: | MARKED TREE | ||||||||
State: | AR | ||||||||
PostalCode: | 723652214 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8703584018 | ||||||||
FaxNumber: | 8703584027 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/18/2007 | ||||||||
LastUpdateDate: | 07/24/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CARTER | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 8707351500 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CRITTENDEN HOSPITAL ASSOCIATION | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | AR4400 | AR | Y |   | Agencies | Home Health |   |
No ID Information.