Provider Demographics
NPI:1023028016
Name:SPAVINAW CLINICS, INC
Entity Type:Organization
Organization Name:SPAVINAW CLINICS, INC
Other - Org Name:DECATUR MEDI CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PATRICK
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:MCCOLLUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-752-3233
Mailing Address - Street 1:PO BOX 735
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AR
Mailing Address - Zip Code:72722-0735
Mailing Address - Country:US
Mailing Address - Phone:479-752-3233
Mailing Address - Fax:479-752-3235
Practice Address - Street 1:346 N. MAIN STREET
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AR
Practice Address - Zip Code:72722-0735
Practice Address - Country:US
Practice Address - Phone:479-752-3232
Practice Address - Fax:479-752-3235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2019-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR043812Medicare Oscar/Certification