Provider Demographics
NPI:1225317621
Name:MED
Entity Type:Organization
Organization Name:MED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:G
Authorized Official - Last Name:WARE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-240-5748
Mailing Address - Street 1:1604 MERRILL DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-1818
Mailing Address - Country:US
Mailing Address - Phone:501-240-5748
Mailing Address - Fax:
Practice Address - Street 1:1604 MERRILL DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-1818
Practice Address - Country:US
Practice Address - Phone:501-240-5748
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-16
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Single Specialty