Provider Demographics
NPI:1376531160
Name:LEACHVILLE PRIMARY CARE CLINIC, INC
Entity Type:Organization
Organization Name:LEACHVILLE PRIMARY CARE CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:S
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-539-1115
Mailing Address - Street 1:PO BOX 580
Mailing Address - Street 2:111 S MAIN ST
Mailing Address - City:LEACHVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72438-0580
Mailing Address - Country:US
Mailing Address - Phone:870-539-1115
Mailing Address - Fax:870-539-1125
Practice Address - Street 1:111 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LEACHVILLE
Practice Address - State:AR
Practice Address - Zip Code:72438-0580
Practice Address - Country:US
Practice Address - Phone:870-539-1115
Practice Address - Fax:870-539-1125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-06
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC8443174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5K184C485Medicare ID - Type Unspecified