Provider Demographics
NPI:1417071572
Name:MONETTE FAMILY PRACTICE CLINIC PA
Entity Type:Organization
Organization Name:MONETTE FAMILY PRACTICE CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING CLERK
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:CHRISTOPHER
Authorized Official - Last Name:ROLLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-486-5464
Mailing Address - Street 1:PO BOX 747
Mailing Address - Street 2:
Mailing Address - City:MONETTE
Mailing Address - State:AR
Mailing Address - Zip Code:72447-0747
Mailing Address - Country:US
Mailing Address - Phone:870-486-5464
Mailing Address - Fax:870-486-2118
Practice Address - Street 1:210 W DREW
Practice Address - Street 2:
Practice Address - City:MONETTE
Practice Address - State:AR
Practice Address - Zip Code:72447-0747
Practice Address - Country:US
Practice Address - Phone:870-486-5464
Practice Address - Fax:870-486-2118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261Q00000X
ARS27098261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR136895762Medicaid
AR136895762Medicaid