Provider Demographics
NPI:1912182445
Name:PRO-MED OF THE JONESBORO, INC
Entity Type:Organization
Organization Name:PRO-MED OF THE JONESBORO, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-931-0022
Mailing Address - Street 1:300 CARSON ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-3104
Mailing Address - Country:US
Mailing Address - Phone:870-931-9565
Mailing Address - Fax:
Practice Address - Street 1:2379 HIGHWAY 62 412
Practice Address - Street 2:SUITE L
Practice Address - City:HIGHLAND
Practice Address - State:AR
Practice Address - Zip Code:72542-9393
Practice Address - Country:US
Practice Address - Phone:870-856-3300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRO-MED OF JONESBORO, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-03
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR48932OtherB/C B/S OF ARKANSAS
AR145632716Medicaid
AR0742190002Medicare NSC