Provider Demographics
NPI:1821104449
Name:VAMC
Entity Type:Organization
Organization Name:VAMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASST
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:479-443-4301
Mailing Address - Street 1:1621 N CHARLEE AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-3066
Mailing Address - Country:US
Mailing Address - Phone:479-444-7376
Mailing Address - Fax:479-587-5996
Practice Address - Street 1:1100 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-1944
Practice Address - Country:US
Practice Address - Phone:479-443-4301
Practice Address - Fax:479-587-5996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA140286500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes286500000XHospitalsMilitary Hospital