Provider Demographics
NPI:1124168919
Name:HEALTH CLINIC EAST
Entity type:Organization
Organization Name:HEALTH CLINIC EAST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHILDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-224-1690
Mailing Address - Street 1:650 S SHACKLEFORD RD
Mailing Address - Street 2:STE 439
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-3522
Mailing Address - Country:US
Mailing Address - Phone:501-224-1690
Mailing Address - Fax:501-224-1927
Practice Address - Street 1:650 S SHACKLEFORD RD
Practice Address - Street 2:STE 439
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-3522
Practice Address - Country:US
Practice Address - Phone:501-224-1690
Practice Address - Fax:501-224-1927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR=========OtherEIN NUMBER