Provider Demographics
NPI:1376517177
Name:NORTHEAST ARKANSAS CLINIC, PA
Entity Type:Organization
Organization Name:NORTHEAST ARKANSAS CLINIC, PA
Other - Org Name:NEA CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ERROL
Authorized Official - Middle Name:SCOT
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-934-5803
Mailing Address - Street 1:P.O. BOX 1960
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72403-1960
Mailing Address - Country:US
Mailing Address - Phone:870-934-5101
Mailing Address - Fax:870-932-3608
Practice Address - Street 1:1835 GRANT AVE.
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401
Practice Address - Country:US
Practice Address - Phone:870-934-5101
Practice Address - Fax:870-932-3608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-16
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR139864002Medicaid
AR139864002Medicaid
4240860001Medicare NSC