Provider Demographics
NPI:1578524856
Name:PLEASANT VALLEY FAMILY CLINIC
Entity Type:Organization
Organization Name:PLEASANT VALLEY FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHARITY
Authorized Official - Middle Name:S
Authorized Official - Last Name:DULIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-224-2875
Mailing Address - Street 1:11719 HINSON RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72212
Mailing Address - Country:US
Mailing Address - Phone:501-224-2875
Mailing Address - Fax:501-224-6357
Practice Address - Street 1:11719 HINSON RD
Practice Address - Street 2:SUITE 110
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72212
Practice Address - Country:US
Practice Address - Phone:501-224-2875
Practice Address - Fax:501-224-6357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE1810207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1350103001Medicaid
5K913Medicare ID - Type Unspecified
AR1350103001Medicaid