Provider Demographics
NPI:1346378528
Name:BOARD OF GOVERNORS OF DALLAS COUNTY MEDICAL CENTER
Entity Type:Organization
Organization Name:BOARD OF GOVERNORS OF DALLAS COUNTY MEDICAL CENTER
Other - Org Name:DALLAS COUNTY MEDICAL CENTER FAMILY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR / CEO
Authorized Official - Prefix:
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:K
Authorized Official - Last Name:RIEVES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-352-6363
Mailing Address - Street 1:201 NORTH CLIFTON STREET
Mailing Address - Street 2:
Mailing Address - City:FORDYCE
Mailing Address - State:AR
Mailing Address - Zip Code:71742
Mailing Address - Country:US
Mailing Address - Phone:870-352-6363
Mailing Address - Fax:870-352-6343
Practice Address - Street 1:201 NORTH CLIFTON STREET
Practice Address - Street 2:
Practice Address - City:FORDYCE
Practice Address - State:AR
Practice Address - Zip Code:71742
Practice Address - Country:US
Practice Address - Phone:870-352-6363
Practice Address - Fax:870-352-6343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR4115261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR148217105Medicaid
AR043494Medicare Oscar/Certification