Provider Demographics
NPI:1912328428
Name:NORTHEAST ARKANSAS CLINIC CHARITABLE FOUNDATION, INC.
Entity Type:Organization
Organization Name:NORTHEAST ARKANSAS CLINIC CHARITABLE FOUNDATION, INC.
Other - Org Name:FOWLER FAMILY CENTER FOR CANCER CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR. VP / CORPORATE SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:M
Authorized Official - Last Name:DUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-227-5233
Mailing Address - Street 1:PO BOX 1960
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72403-1960
Mailing Address - Country:US
Mailing Address - Phone:870-336-1485
Mailing Address - Fax:870-336-1484
Practice Address - Street 1:4808 E JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-8413
Practice Address - Country:US
Practice Address - Phone:870-936-8000
Practice Address - Fax:870-932-3608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-31
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0200XAmbulatory Health Care FacilitiesClinic/CenterOncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR184473002Medicaid
AR5G237OtherBCBS
AR5G466Medicare PIN