Provider Demographics
NPI:1922475045
Name:BAXTER REGIONAL CENTER FOR INTEGRATIVE MEDICINE, LLC
Entity Type:Organization
Organization Name:BAXTER REGIONAL CENTER FOR INTEGRATIVE MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-508-1018
Mailing Address - Street 1:610 BROADMOOR DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-2903
Mailing Address - Country:US
Mailing Address - Phone:870-508-7530
Mailing Address - Fax:
Practice Address - Street 1:610 BROADMOOR DR
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-2903
Practice Address - Country:US
Practice Address - Phone:870-508-7530
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2090207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty