Basic Information
| Provider Information | |||||||||
| NPI: | 1710173372 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE PUBLIC BUILDING AUTHORITY OF THE CITY OF POCAHONTAS ARKANSAS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 504 TEXAS ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711013526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182268202 | ||||||||
| FaxNumber: | 3182268205 | ||||||||
| Practice Location | |||||||||
| Address1: | 2801 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | POCAHONTAS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724559436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182268202 | ||||||||
| FaxNumber: | 3182268205 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2007 | ||||||||
| LastUpdateDate: | 11/01/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BORDELON | ||||||||
| AuthorizedOfficialFirstName: | ROCK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3182268202 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | THE PUBLIC BUILDING AUTHORITY OF THE CITY OF POCAHONTAS ARKANSAS | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | Y | Agencies | Home Health |
No ID Information.