Provider Demographics
NPI:1417123258
Name:DEPARTMENT OF VETERANS AFFAIRS
Entity type:Organization
Organization Name:DEPARTMENT OF VETERANS AFFAIRS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF NURSE
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:D
Authorized Official - Last Name:GREATHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:870-216-2512
Mailing Address - Street 1:1107 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-5066
Mailing Address - Country:US
Mailing Address - Phone:903-824-4181
Mailing Address - Fax:
Practice Address - Street 1:910 REALTOR AVENUE
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-5066
Practice Address - Country:US
Practice Address - Phone:870-824-4181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARL29493261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)