Provider Demographics
NPI:1023361938
Name:ADVANCE THERAPY OF NORTHEAST ARKANSAS,LLC
Entity Type:Organization
Organization Name:ADVANCE THERAPY OF NORTHEAST ARKANSAS,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINSTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:WYNNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-563-1331
Mailing Address - Street 1:315 E UNION AVE
Mailing Address - Street 2:
Mailing Address - City:OSCEOLA
Mailing Address - State:AR
Mailing Address - Zip Code:72370-3235
Mailing Address - Country:US
Mailing Address - Phone:870-563-1331
Mailing Address - Fax:870-563-1334
Practice Address - Street 1:315 E UNION AVE
Practice Address - Street 2:
Practice Address - City:OSCEOLA
Practice Address - State:AR
Practice Address - Zip Code:72370-3235
Practice Address - Country:US
Practice Address - Phone:870-563-1331
Practice Address - Fax:870-563-1334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR=========Medicaid