Provider Demographics
NPI:1063514388
Name:CAVS
Entity type:Organization
Organization Name:CAVS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:TERENCE
Authorized Official - Middle Name:BENJAMIN
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-257-2627
Mailing Address - Street 1:11C/NLR TOWBIN HEALTH CARE 2200 FORT ROOTS DRIVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72114
Mailing Address - Country:US
Mailing Address - Phone:501-257-2627
Mailing Address - Fax:
Practice Address - Street 1:11C/NLR TOWBIN HEALTH CARE 2200 FORT ROOTS DRIVE
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72114
Practice Address - Country:US
Practice Address - Phone:501-257-2627
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4907261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care