Provider Demographics
NPI:1649593187
Name:CHILD & YOUTH PEDIATRIC DAY CLINIC
Entity Type:Organization
Organization Name:CHILD & YOUTH PEDIATRIC DAY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:HOGARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-933-9528
Mailing Address - Street 1:806 GLENDALE ST
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-4455
Mailing Address - Country:US
Mailing Address - Phone:870-933-9528
Mailing Address - Fax:
Practice Address - Street 1:806 GLENDALE ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-4455
Practice Address - Country:US
Practice Address - Phone:870-933-9528
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-11
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR160767742Medicaid
AR160740526Medicaid
AR160751724Medicaid