Provider Demographics
NPI:1497168397
Name:SOUTH CENTRAL MEDICAL SERVICES, P.A.
Entity Type:Organization
Organization Name:SOUTH CENTRAL MEDICAL SERVICES, P.A.
Other - Org Name:RENAISSANCE HEALTH AND WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHESTER
Authorized Official - Middle Name:L
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:479-657-6888
Mailing Address - Street 1:PO BOX 11020
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72917-1020
Mailing Address - Country:US
Mailing Address - Phone:479-434-4887
Mailing Address - Fax:479-434-4955
Practice Address - Street 1:600 AUTUMN RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-3606
Practice Address - Country:US
Practice Address - Phone:501-448-2342
Practice Address - Fax:501-221-0615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-09
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE5307208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty