Provider Demographics
NPI:1831257070
Name:CHILD & ADOLESCENT CLINIC
Entity type:Organization
Organization Name:CHILD & ADOLESCENT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:VERN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SHOTTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-239-5437
Mailing Address - Street 1:1204 W KINGSHIGHWAY
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-4143
Mailing Address - Country:US
Mailing Address - Phone:870-239-5437
Mailing Address - Fax:870-239-4211
Practice Address - Street 1:1204 W KINGSHIGHWAY
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-4143
Practice Address - Country:US
Practice Address - Phone:870-239-5437
Practice Address - Fax:870-239-4211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5B870OtherBLUE CROSS