Basic Information
| Provider Information | |||||||||
| NPI: | 1912431818 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | 1ST CHOICE HEALTHCARE INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | 1ST CHOICE HEALTHCARE SALEM | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 83 | ||||||||
| Address2: | |||||||||
| City: | CORNING | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724220083 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708573334 | ||||||||
| FaxNumber: | 8708579934 | ||||||||
| Practice Location | |||||||||
| Address1: | 172 HIGHWAY 62 W | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | AR | ||||||||
| PostalCode: | 725768059 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708952735 | ||||||||
| FaxNumber: | 8708952709 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2017 | ||||||||
| LastUpdateDate: | 04/14/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WELLS | ||||||||
| AuthorizedOfficialFirstName: | BECKY | ||||||||
| AuthorizedOfficialMiddleName: | JO | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 8708573334 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | 1ST CHOICE HEALTHCARE, INC. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 220551749 | 05 | AR | MEDICAID |