Basic Information
| Provider Information | |||||||||
| NPI: | 1801127030 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHEAST ARKANSAS CLINIC CHARITABLE FOUNDATION, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NEA BAPTIST CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 N HUMPHREYS BLVD | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381202177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012275233 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4802 E. JOHNSON AVENUE | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709368000 | ||||||||
| FaxNumber: | 8709323608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2010 | ||||||||
| LastUpdateDate: | 09/30/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | DUCKETT | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SR VP/ CLO | ||||||||
| AuthorizedOfficialTelephone: | 9012275233 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.