Provider Demographics
NPI:1962626770
Name:LAWRENCE MEMORIAL HEALTH FOUNDATION INC.
Entity Type:Organization
Organization Name:LAWRENCE MEMORIAL HEALTH FOUNDATION INC.
Other - Org Name:LAWRENCE MEMORIAL PHYSICIAN GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MRS
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:K
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-886-1263
Mailing Address - Street 1:1309 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WALNUT RIDGE
Mailing Address - State:AR
Mailing Address - Zip Code:72476-1430
Mailing Address - Country:US
Mailing Address - Phone:870-886-1252
Mailing Address - Fax:870-886-3388
Practice Address - Street 1:1309 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WALNUT RIDGE
Practice Address - State:AR
Practice Address - Zip Code:72476-1430
Practice Address - Country:US
Practice Address - Phone:870-886-1252
Practice Address - Fax:870-886-3388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR38420282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR103154002Medicaid
AR103154002Medicaid