Provider Demographics
NPI:1174826499
Name:CENTER FOR PEDIATRIC NEUROSCIENCE, PLLC
Entity Type:Organization
Organization Name:CENTER FOR PEDIATRIC NEUROSCIENCE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOB
Authorized Official - Middle Name:D
Authorized Official - Last Name:CASPALL
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:901-603-9936
Mailing Address - Street 1:PO BOX 814
Mailing Address - Street 2:
Mailing Address - City:WALNUT RIDGE
Mailing Address - State:AR
Mailing Address - Zip Code:72476-0814
Mailing Address - Country:US
Mailing Address - Phone:901-603-9936
Mailing Address - Fax:
Practice Address - Street 1:2808 FOX MEADOW LN
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72404-9346
Practice Address - Country:US
Practice Address - Phone:870-932-4245
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-08
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR11-16P103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3583920Medicaid
TN4302608OtherBLUE CROSS BLUE SHIELD
MS00118484Medicaid
AR189059744Medicaid