Provider Demographics
NPI:1588000228
Name:BLYTHEVILLE RT ASSOCIATES LLC
Entity Type:Organization
Organization Name:BLYTHEVILLE RT ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:M
Authorized Official - Last Name:PRENTICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-418-2200
Mailing Address - Street 1:11101 HEFNER POINTE DR
Mailing Address - Street 2:STE 209
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-5054
Mailing Address - Country:US
Mailing Address - Phone:405-418-2900
Mailing Address - Fax:405-418-2907
Practice Address - Street 1:1522 N DIVISION ST
Practice Address - Street 2:
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315-1448
Practice Address - Country:US
Practice Address - Phone:870-762-1400
Practice Address - Fax:870-762-1403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-21
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty