Provider Demographics
NPI:1255746772
Name:PETTY MEDICAL CLINIC, LLC
Entity type:Organization
Organization Name:PETTY MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CORWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PETTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-502-4435
Mailing Address - Street 1:114 HARRISON AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745-9047
Mailing Address - Country:US
Mailing Address - Phone:479-254-1005
Mailing Address - Fax:479-668-4003
Practice Address - Street 1:114 HARRISON AVE
Practice Address - Street 2:SUITE C
Practice Address - City:LOWELL
Practice Address - State:AR
Practice Address - Zip Code:72745-9047
Practice Address - Country:US
Practice Address - Phone:479-254-1005
Practice Address - Fax:479-668-4003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-23
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2717261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care