Basic Information
| Provider Information | |||||||||
| NPI: | 1922120765 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SCROGGINS | ||||||||
| FirstName: | OLIVER | ||||||||
| MiddleName: | MARC | ||||||||
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| Credential: | MHPP | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3352 N FUTRALL DR | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727034057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4795215868 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1484 W 1ST ST N | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AR | ||||||||
| PostalCode: | 718573339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708871078 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2007 | ||||||||
| LastUpdateDate: | 08/29/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.