Provider Demographics
NPI:1386743482
Name:SCARBROUGH CLINIC, INC.
Entity type:Organization
Organization Name:SCARBROUGH CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP/CHIROPRACTOR/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TAD
Authorized Official - Middle Name:
Authorized Official - Last Name:SCARBROUGH
Authorized Official - Suffix:
Authorized Official - Credentials:APRN, DC
Authorized Official - Phone:870-238-8707
Mailing Address - Street 1:PO BOX 572
Mailing Address - Street 2:
Mailing Address - City:WYNNE
Mailing Address - State:AR
Mailing Address - Zip Code:72396-0572
Mailing Address - Country:US
Mailing Address - Phone:870-238-8707
Mailing Address - Fax:870-533-5573
Practice Address - Street 1:1901 KILLOUGH RD. NORTH
Practice Address - Street 2:
Practice Address - City:WYNNE
Practice Address - State:AR
Practice Address - Zip Code:72396-2465
Practice Address - Country:US
Practice Address - Phone:870-238-8707
Practice Address - Fax:870-238-8711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1544111N00000X
ARP01329164W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR647764OtherUNITED HEALTHCARE ID #
AR158844718Medicaid
AR19754000040OtherQUALCHOICE ID NUMBER
AR7359415OtherAETNA ID NUMBER
AR3821243OtherCIGNA ID NUMBER
AR5U931OtherAR BLUECROSSBLUESHIELD
AR7359415OtherAETNA ID NUMBER
AR158844718Medicaid
AR=========OtherAMCO ID #