Provider Demographics
NPI:1700943636
Name:MCKENZIE ORTHOPEDIC AND SPORTS CLINIC
Entity Type:Organization
Organization Name:MCKENZIE ORTHOPEDIC AND SPORTS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:MCKENZIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-273-1111
Mailing Address - Street 1:1504 SE 28TH ST
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-3988
Mailing Address - Country:US
Mailing Address - Phone:479-273-1111
Mailing Address - Fax:
Practice Address - Street 1:1504 SE 28TH ST
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-3988
Practice Address - Country:US
Practice Address - Phone:479-273-1111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARCS8254OtherRAILROAD MEDICARE