Provider Demographics
NPI:1508036146
Name:JOHNNY L. BOWMAN
Entity Type:Organization
Organization Name:JOHNNY L. BOWMAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:PERRIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-845-3725
Mailing Address - Street 1:410 N MAIN ST STE 3
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:71852-2000
Mailing Address - Country:US
Mailing Address - Phone:870-845-3725
Mailing Address - Fax:870-845-3322
Practice Address - Street 1:410 N MAIN ST STE 3
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:AR
Practice Address - Zip Code:71852-2000
Practice Address - Country:US
Practice Address - Phone:870-845-3725
Practice Address - Fax:870-845-3322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-11
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2365302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR0828960001Medicare NSC