Provider Demographics
NPI:1194299289
Name:MISSION PROPERTIES GROUP, LLC
Entity type:Organization
Organization Name:MISSION PROPERTIES GROUP, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VAN
Authorized Official - Middle Name:H
Authorized Official - Last Name:DE BRUYN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-399-4212
Mailing Address - Street 1:12 SPRING VALLEY LN
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72223-4494
Mailing Address - Country:US
Mailing Address - Phone:501-399-4212
Mailing Address - Fax:501-868-7551
Practice Address - Street 1:11220 EXECUTIVE CENTER DR STE 200
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-4492
Practice Address - Country:US
Practice Address - Phone:501-399-4212
Practice Address - Fax:501-868-7551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-11
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac ElectrophysiologyGroup - Multi-Specialty