Provider Demographics
NPI:1275960155
Name:THE SHOT CLINIC, LLC
Entity Type:Organization
Organization Name:THE SHOT CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:E
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-225-7468
Mailing Address - Street 1:10720 N RODNEY PARHAM RD
Mailing Address - Street 2:SUITE B5
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72212-4177
Mailing Address - Country:US
Mailing Address - Phone:501-225-7468
Mailing Address - Fax:501-224-1834
Practice Address - Street 1:10720 N RODNEY PARHAM RD
Practice Address - Street 2:SUITE B5
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72212-4177
Practice Address - Country:US
Practice Address - Phone:501-225-7468
Practice Address - Fax:501-224-1834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-09
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-5114261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health