Provider Demographics
NPI:1649237165
Name:ARK-LA-TEX HEALTH CENTER PC
Entity Type:Organization
Organization Name:ARK-LA-TEX HEALTH CENTER PC
Other - Org Name:ARK-LA-TEX HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:D
Authorized Official - Last Name:RAKER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:870-773-7246
Mailing Address - Street 1:1414 ARKANSAS BLVD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-1604
Mailing Address - Country:US
Mailing Address - Phone:870-773-7246
Mailing Address - Fax:870-772-2568
Practice Address - Street 1:1414 ARKANSAS BLVD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-1604
Practice Address - Country:US
Practice Address - Phone:870-773-7246
Practice Address - Fax:870-772-2568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1141111N00000X
ARN8393207Q00000X
ARA01334363LA2100X
ARAO3679363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR152398002Medicaid
AR152398002Medicaid