Provider Demographics
NPI:1578909362
Name:DYSON PSYCHIACTRIC CARE, LLC
Entity Type:Organization
Organization Name:DYSON PSYCHIACTRIC CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CORI
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:DYSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-972-1497
Mailing Address - Street 1:PO BOX 17253
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72403-6723
Mailing Address - Country:US
Mailing Address - Phone:870-972-1497
Mailing Address - Fax:866-422-5771
Practice Address - Street 1:820 E MATTHEWS AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3048
Practice Address - Country:US
Practice Address - Phone:870-972-1497
Practice Address - Fax:866-422-5771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-20
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-5305261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5N859F812Medicare PIN