Provider Demographics
NPI:1346643020
Name:LAWRENCE MEMORIAL HEALTH FOUNDATION INC.
Entity Type:Organization
Organization Name:LAWRENCE MEMORIAL HEALTH FOUNDATION INC.
Other - Org Name:IMBODEN RURAL HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:K
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-886-1263
Mailing Address - Street 1:PO BOX 839
Mailing Address - Street 2:
Mailing Address - City:WALNUT RIDGE
Mailing Address - State:AR
Mailing Address - Zip Code:72476-0839
Mailing Address - Country:US
Mailing Address - Phone:870-886-1200
Mailing Address - Fax:870-886-5340
Practice Address - Street 1:201 N WALNUT STREET
Practice Address - Street 2:
Practice Address - City:IMBODEN
Practice Address - State:AR
Practice Address - Zip Code:72434
Practice Address - Country:US
Practice Address - Phone:870-869-3101
Practice Address - Fax:870-869-3014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-08
Last Update Date:2019-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health