Provider Demographics
NPI:1396102679
Name:LIVING TREE PEDIATRICS, PLLC
Entity type:Organization
Organization Name:LIVING TREE PEDIATRICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:LYNETTE
Authorized Official - Last Name:TATE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-282-2966
Mailing Address - Street 1:P.O. BOX 2760
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-4290
Mailing Address - Country:US
Mailing Address - Phone:479-282-2966
Mailing Address - Fax:479-282-2967
Practice Address - Street 1:1110 SE 30TH STREET
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-4290
Practice Address - Country:US
Practice Address - Phone:479-282-2966
Practice Address - Fax:479-282-2967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-18
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE7529208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR191183001Medicaid
AR192425001Medicaid
AR192425001Medicaid
AR191183001Medicaid
AR1578731154OtherNPI