Provider Demographics
NPI:1609256452
Name:THE PEDIATRIC PROMISE CENTER LLC
Entity Type:Organization
Organization Name:THE PEDIATRIC PROMISE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INCORPORATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KALA
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:PRICE
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:479-806-4914
Mailing Address - Street 1:5653 HIGHWAY 282
Mailing Address - Street 2:
Mailing Address - City:RUDY
Mailing Address - State:AR
Mailing Address - Zip Code:72952-9008
Mailing Address - Country:US
Mailing Address - Phone:479-806-4914
Mailing Address - Fax:
Practice Address - Street 1:5653 HIGHWAY 282
Practice Address - Street 2:
Practice Address - City:RUDY
Practice Address - State:AR
Practice Address - Zip Code:72952-9008
Practice Address - Country:US
Practice Address - Phone:479-806-4914
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-08
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty