Provider Demographics
NPI:1255429726
Name:BOSTON MOUNTAIN RURAL HEALTH CENTER, INC
Entity type:Organization
Organization Name:BOSTON MOUNTAIN RURAL HEALTH CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-448-5101
Mailing Address - Street 1:PO BOX 1060
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:AR
Mailing Address - Zip Code:72650-1060
Mailing Address - Country:US
Mailing Address - Phone:870-448-5101
Mailing Address - Fax:870-448-4769
Practice Address - Street 1:110 VILLAGE VILLAGE PLACE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD BAY
Practice Address - State:AR
Practice Address - Zip Code:72088
Practice Address - Country:US
Practice Address - Phone:501-884-6898
Practice Address - Fax:501-884-6831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5B477OtherBLUE CROSS ARKANSAS GROUP
AR041838Medicare Oscar/Certification