Provider Demographics
NPI:1003877036
Name:BALD KNOB HEALTHCARE CENTER, PA
Entity Type:Organization
Organization Name:BALD KNOB HEALTHCARE CENTER, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL OFFICE ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:HOLDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-724-3110
Mailing Address - Street 1:PO BOX 1158
Mailing Address - Street 2:
Mailing Address - City:BALD KNOB
Mailing Address - State:AR
Mailing Address - Zip Code:72010-1158
Mailing Address - Country:US
Mailing Address - Phone:501-724-3110
Mailing Address - Fax:501-724-0140
Practice Address - Street 1:2104 HIGHWAY 367 N
Practice Address - Street 2:
Practice Address - City:BALD KNOB
Practice Address - State:AR
Practice Address - Zip Code:72010-9443
Practice Address - Country:US
Practice Address - Phone:501-724-3110
Practice Address - Fax:501-724-0140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2849261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5C933OtherBLUE CROSS
AR0100548OtherUNITED HEATLHCARE
AR152204002Medicaid
AR02080000800OtherQUALCHOICE
AR152204002Medicaid
ARH35824Medicare UPIN