Provider Demographics
NPI:1104356419
Name:DE QUEEN MEDICAL CENTER DIALYSIS
Entity Type:Organization
Organization Name:DE QUEEN MEDICAL CENTER DIALYSIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRAMY
Authorized Official - Middle Name:
Authorized Official - Last Name:ICENHOWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-584-0272
Mailing Address - Street 1:1306 W COLLIN RAYE DR
Mailing Address - Street 2:
Mailing Address - City:DE QUEEN
Mailing Address - State:AR
Mailing Address - Zip Code:71832-2502
Mailing Address - Country:US
Mailing Address - Phone:870-584-4111
Mailing Address - Fax:870-584-4100
Practice Address - Street 1:1306 W COLLIN RAYE DR
Practice Address - Street 2:
Practice Address - City:DE QUEEN
Practice Address - State:AR
Practice Address - Zip Code:71832-2502
Practice Address - Country:US
Practice Address - Phone:870-584-4111
Practice Address - Fax:870-584-4100
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DE QUEEN MEDICAL CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment