Provider Demographics
NPI:1679701213
Name:MENA HEART AND VASCULAR CLINIC
Entity Type:Organization
Organization Name:MENA HEART AND VASCULAR CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BOB
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLZEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-394-6100
Mailing Address - Street 1:PO BOX 295
Mailing Address - Street 2:
Mailing Address - City:LOCKESBURG
Mailing Address - State:AR
Mailing Address - Zip Code:71846-0295
Mailing Address - Country:US
Mailing Address - Phone:870-289-5865
Mailing Address - Fax:870-289-6993
Practice Address - Street 1:403 MORROW ST N
Practice Address - Street 2:SUITE G
Practice Address - City:MENA
Practice Address - State:AR
Practice Address - Zip Code:71953-4324
Practice Address - Country:US
Practice Address - Phone:479-394-6100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-22
Last Update Date:2009-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE5746207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty