Provider Demographics
NPI:1285909036
Name:MAHAN, TOMMY RAY
Entity type:Individual
Prefix:
First Name:TOMMY
Middle Name:RAY
Last Name:MAHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15
Mailing Address - Street 2:
Mailing Address - City:CENTER RIDGE
Mailing Address - State:AR
Mailing Address - Zip Code:72027-0015
Mailing Address - Country:US
Mailing Address - Phone:501-208-6938
Mailing Address - Fax:
Practice Address - Street 1:3693 HWY 92 W
Practice Address - Street 2:
Practice Address - City:CENTER RIDGE
Practice Address - State:AR
Practice Address - Zip Code:72027
Practice Address - Country:US
Practice Address - Phone:501-208-6938
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-13
Last Update Date:2012-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR189358783Medicaid