Provider Demographics
NPI:1760736565
Name:HEALTH FOR LIFE CLINIC PLLC
Entity Type:Organization
Organization Name:HEALTH FOR LIFE CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PROCTOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-603-0003
Mailing Address - Street 1:1100 N UNIVERSITY AVE
Mailing Address - Street 2:STE 260
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72207-6343
Mailing Address - Country:US
Mailing Address - Phone:501-603-0003
Mailing Address - Fax:501-603-0030
Practice Address - Street 1:1100 N UNIVERSITY AVE
Practice Address - Street 2:STE 260
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72207-6343
Practice Address - Country:US
Practice Address - Phone:501-603-0003
Practice Address - Fax:501-603-0030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-31
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4604208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR104422001Medicaid
ARB90333Medicare UPIN
AR52647Medicare PIN