Provider Demographics
NPI:1033491519
Name:NORTHEAST ARKANSAS CLINIC CHARITABLE FOUNDATION, INC.
Entity Type:Organization
Organization Name:NORTHEAST ARKANSAS CLINIC CHARITABLE FOUNDATION, INC.
Other - Org Name:NEA BAPTIST CLINIC DIALYSIS CENTER/HILLTOP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP/ CLO
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:M
Authorized Official - Last Name:DUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-227-5233
Mailing Address - Street 1:350 N HUMPHREYS BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2177
Mailing Address - Country:US
Mailing Address - Phone:901-227-5233
Mailing Address - Fax:
Practice Address - Street 1:4909 EAST JOHNSON AVE.
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401
Practice Address - Country:US
Practice Address - Phone:870-336-3372
Practice Address - Fax:870-934-3658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-12
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR12577OtherBCBS
AR200341134Medicaid
AR12577OtherBCBS