Provider Demographics
NPI:1700211885
Name:FORT SMITH NEUROSCIENCE CENTER, PLLC.
Entity Type:Organization
Organization Name:FORT SMITH NEUROSCIENCE CENTER, PLLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:P
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-434-3544
Mailing Address - Street 1:PO BOX 180969
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72918-0969
Mailing Address - Country:US
Mailing Address - Phone:479-434-3544
Mailing Address - Fax:479-434-3547
Practice Address - Street 1:7217 CAMERON PARK DRIVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903
Practice Address - Country:US
Practice Address - Phone:479-434-3544
Practice Address - Fax:479-434-3547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-09
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE6954174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty