Provider Demographics
NPI:1962631523
Name:CORE EMPOWERMENT GROUP LLC
Entity Type:Organization
Organization Name:CORE EMPOWERMENT GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:COLLIE
Authorized Official - Suffix:IV
Authorized Official - Credentials:MD
Authorized Official - Phone:501-920-7901
Mailing Address - Street 1:1201 MILITARY RD
Mailing Address - Street 2:STE 2 PMB 269
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-2908
Mailing Address - Country:US
Mailing Address - Phone:501-920-7901
Mailing Address - Fax:501-325-3469
Practice Address - Street 1:17724 INTERSTATE 30
Practice Address - Street 2:STE 2
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72019-2907
Practice Address - Country:US
Practice Address - Phone:501-920-7901
Practice Address - Fax:501-325-3469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-03
Last Update Date:2009-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR-2220261QG0250X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QG0250XAmbulatory Health Care FacilitiesClinic/CenterGenetics