Provider Demographics
NPI:1831220334
Name:PEDIATRIC SPECIALTY CARE
Entity type:Organization
Organization Name:PEDIATRIC SPECIALTY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH PROFESSIONAL
Authorized Official - Prefix:MR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:LAMAR
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:870-245-2210
Mailing Address - Street 1:141 GRISHAM RD
Mailing Address - Street 2:
Mailing Address - City:ROYAL
Mailing Address - State:AR
Mailing Address - Zip Code:71968-9563
Mailing Address - Country:US
Mailing Address - Phone:501-282-2750
Mailing Address - Fax:
Practice Address - Street 1:2410 PINE ST
Practice Address - Street 2:
Practice Address - City:ARKADELPHIA
Practice Address - State:AR
Practice Address - Zip Code:71923-4335
Practice Address - Country:US
Practice Address - Phone:870-245-2210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP0607039302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization