Provider Demographics
NPI:1609631415
Name:THE CLINIC
Entity Type:Organization
Organization Name:THE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-813-0300
Mailing Address - Street 1:402 SW LARKSPUR DR
Mailing Address - Street 2:
Mailing Address - City:WALNUT RIDGE
Mailing Address - State:AR
Mailing Address - Zip Code:72476-1750
Mailing Address - Country:US
Mailing Address - Phone:870-813-0300
Mailing Address - Fax:870-313-0380
Practice Address - Street 1:402 SW LARKSPUR DR
Practice Address - Street 2:
Practice Address - City:WALNUT RIDGE
Practice Address - State:AR
Practice Address - Zip Code:72476-1750
Practice Address - Country:US
Practice Address - Phone:870-813-0300
Practice Address - Fax:870-313-0380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty