Provider Demographics
NPI:1154382307
Name:NORTH LITTLE ROCK PET ASSOCIATES, LLC
Entity type:Organization
Organization Name:NORTH LITTLE ROCK PET ASSOCIATES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:WICKERSHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-418-2200
Mailing Address - Street 1:PO BOX 15603
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72231-5603
Mailing Address - Country:US
Mailing Address - Phone:501-687-1154
Mailing Address - Fax:501-687-1289
Practice Address - Street 1:3500 SPRINGHILL DR
Practice Address - Street 2:STE 100
Practice Address - City:N LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72117-2950
Practice Address - Country:US
Practice Address - Phone:501-687-1154
Practice Address - Fax:501-687-1289
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARARK-991-AP-BP-08-12247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5F437Medicare ID - Type Unspecified