Provider Demographics
NPI:1841408788
Name:FAYETTEVILLE-SPRINGDALE EAR, NOSE & THROAT CLINIC
Entity type:Organization
Organization Name:FAYETTEVILLE-SPRINGDALE EAR, NOSE & THROAT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-521-1238
Mailing Address - Street 1:4255 N VENETIAN LN
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-5077
Mailing Address - Country:US
Mailing Address - Phone:479-521-1238
Mailing Address - Fax:479-521-0509
Practice Address - Street 1:4255 N VENETIAN LN
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-5077
Practice Address - Country:US
Practice Address - Phone:479-521-1238
Practice Address - Fax:479-521-0509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty