Provider Demographics
NPI:1225095524
Name:PELLEGRINO CENTER FOR CLINICAL NEUROSCIENCE
Entity Type:Organization
Organization Name:PELLEGRINO CENTER FOR CLINICAL NEUROSCIENCE
Other - Org Name:P.C.C.N.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:G
Authorized Official - Last Name:PELLEGRINO
Authorized Official - Suffix:
Authorized Official - Credentials:MD,PHD
Authorized Official - Phone:501-623-0280
Mailing Address - Street 1:1 MERCY LN
Mailing Address - Street 2:SUITE 505
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71913-6442
Mailing Address - Country:US
Mailing Address - Phone:501-623-0280
Mailing Address - Fax:501-623-2405
Practice Address - Street 1:1 MERCY LN
Practice Address - Street 2:SUITE 505
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71913-6442
Practice Address - Country:US
Practice Address - Phone:501-623-0280
Practice Address - Fax:501-623-2405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-28
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN7649174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5B454Medicare PIN