Provider Demographics
NPI:1609872142
Name:DTR MEDICAL, INC
Entity Type:Organization
Organization Name:DTR MEDICAL, INC
Other - Org Name:WOMEN'S PAVILION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:S
Authorized Official - Last Name:LITTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-936-7050
Mailing Address - Street 1:122 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-4502
Mailing Address - Country:US
Mailing Address - Phone:479-936-7050
Mailing Address - Fax:479-936-7080
Practice Address - Street 1:122 S 1ST ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-4502
Practice Address - Country:US
Practice Address - Phone:479-936-7050
Practice Address - Fax:479-936-7080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-21
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR154549716Medicaid