Provider Demographics
NPI:1265620868
Name:DEBRA FAULKNER
Entity type:Organization
Organization Name:DEBRA FAULKNER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:FAULKNER
Authorized Official - Suffix:
Authorized Official - Credentials:RT
Authorized Official - Phone:870-310-0321
Mailing Address - Street 1:3025 N WYATT DR
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730-4189
Mailing Address - Country:US
Mailing Address - Phone:870-310-0321
Mailing Address - Fax:870-862-2074
Practice Address - Street 1:3025 N WYATT DR
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-4189
Practice Address - Country:US
Practice Address - Phone:870-310-0321
Practice Address - Fax:870-862-2074
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-09
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR140983710Medicaid
AR140983710Medicaid