Provider Demographics
NPI:1386944791
Name:NORTHWEST ARKANSAS IMMUNIZATION
Entity type:Organization
Organization Name:NORTHWEST ARKANSAS IMMUNIZATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIA-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:L
Authorized Official - Last Name:CADLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-273-5437
Mailing Address - Street 1:PO BOX 9178
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-9178
Mailing Address - Country:US
Mailing Address - Phone:479-968-4273
Mailing Address - Fax:479-968-1363
Practice Address - Street 1:2719 SE I ST
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-3996
Practice Address - Country:US
Practice Address - Phone:479-273-5437
Practice Address - Fax:479-273-9932
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-01
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty