Provider Demographics
NPI:1225289978
Name:OUACHITA FAMILY PRACTICE LLC
Entity Type:Organization
Organization Name:OUACHITA FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KINCAID
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-394-5068
Mailing Address - Street 1:PO BOX 1788
Mailing Address - Street 2:
Mailing Address - City:MENA
Mailing Address - State:AR
Mailing Address - Zip Code:71953-1781
Mailing Address - Country:US
Mailing Address - Phone:479-394-5068
Mailing Address - Fax:
Practice Address - Street 1:1210 DEQUEEN ST
Practice Address - Street 2:
Practice Address - City:MENA
Practice Address - State:AR
Practice Address - Zip Code:71953-4132
Practice Address - Country:US
Practice Address - Phone:479-394-5068
Practice Address - Fax:479-394-5626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-30
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARN6236207Q00000X
ARA01300-ANP363LF0000X
ARA03080ANP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5A866OtherPTAN
AR175314762Medicaid
AR182122002Medicaid
AR5U119OtherPTAN