Provider Demographics
NPI:1114058682
Name:PROSPECTIVE HEALTH LTD
Entity type:Organization
Organization Name:PROSPECTIVE HEALTH LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:E
Authorized Official - Last Name:SALMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-303-7779
Mailing Address - Street 1:1304 MILITARY RD
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015
Mailing Address - Country:US
Mailing Address - Phone:501-778-0934
Mailing Address - Fax:501-778-8377
Practice Address - Street 1:1304 MILITARY RD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015
Practice Address - Country:US
Practice Address - Phone:501-778-0934
Practice Address - Fax:501-778-8377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR110153002Medicaid
AR57878Medicare PIN