Provider Demographics
NPI:1578684148
Name:POINTER TRAIL FAMILY CLINIC PLLC
Entity Type:Organization
Organization Name:POINTER TRAIL FAMILY CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:M
Authorized Official - Last Name:DILLARD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:479-922-2222
Mailing Address - Street 1:109 W POINTER TRAIL
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-5321
Mailing Address - Country:US
Mailing Address - Phone:479-922-2222
Mailing Address - Fax:479-922-2227
Practice Address - Street 1:109 W POINTER TRAIL
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956-5321
Practice Address - Country:US
Practice Address - Phone:479-922-2222
Practice Address - Fax:479-922-2227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC2545207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5F756OtherGROUP MEDICARE NUMBER