Provider Demographics
NPI:1588692198
Name:THE PEDIATRIC CLINIC OF NLR, P.A.
Entity type:Organization
Organization Name:THE PEDIATRIC CLINIC OF NLR, P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:501-758-1530
Mailing Address - Street 1:1525 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72120-5076
Mailing Address - Country:US
Mailing Address - Phone:501-758-1530
Mailing Address - Fax:501-819-6171
Practice Address - Street 1:1525 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:AR
Practice Address - Zip Code:72120-5076
Practice Address - Country:US
Practice Address - Phone:501-758-1530
Practice Address - Fax:501-819-6171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR56918OtherBLUCROSS BLUSHIELD AR
OK200077770AMedicaid
AR104480002Medicaid