Provider Demographics
NPI:1265569453
Name:PEDIATRIC NUTRITION PROVIDER OF ARKANSAS
Entity type:Organization
Organization Name:PEDIATRIC NUTRITION PROVIDER OF ARKANSAS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:C
Authorized Official - Last Name:MOTTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-315-7337
Mailing Address - Street 1:920 EDISON AVE
Mailing Address - Street 2:SUITE 8
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-4502
Mailing Address - Country:US
Mailing Address - Phone:501-315-7337
Mailing Address - Fax:
Practice Address - Street 1:920 EDISON AVE
Practice Address - Street 2:SUITE 8
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-4502
Practice Address - Country:US
Practice Address - Phone:501-315-7337
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMG00511332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR49908OtherBCBS
AR4673130001Medicare ID - Type UnspecifiedMEDICARE REGION C