Provider Demographics
NPI:1649285511
Name:FONTICIELLA MEDICAL CLINIC, INC
Entity type:Organization
Organization Name:FONTICIELLA MEDICAL CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:ADALBERTO
Authorized Official - Middle Name:RAMON
Authorized Official - Last Name:FONTICIELLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-236-6930
Mailing Address - Street 1:1000 WEST KINGSHIGHWAY
Mailing Address - Street 2:SUITE 12
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-8894
Mailing Address - Country:US
Mailing Address - Phone:870-236-6930
Mailing Address - Fax:870-239-8065
Practice Address - Street 1:1000 WEST KINGSHIGHWAY
Practice Address - Street 2:SUITE 12
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-8894
Practice Address - Country:US
Practice Address - Phone:870-236-6930
Practice Address - Fax:870-239-8065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-29
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC6766174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR157456002Medicaid
AR157456002Medicaid