Provider Demographics
NPI:1699741033
Name:ARKADELPHIA CLINIC FOR CHILDREN AND YOUNG ADULTS, PA
Entity type:Organization
Organization Name:ARKADELPHIA CLINIC FOR CHILDREN AND YOUNG ADULTS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:KLUCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-246-8036
Mailing Address - Street 1:2850 TWIN RIVERS DR
Mailing Address - Street 2:
Mailing Address - City:ARKADELPHIA
Mailing Address - State:AR
Mailing Address - Zip Code:71923-4212
Mailing Address - Country:US
Mailing Address - Phone:870-246-8036
Mailing Address - Fax:870-246-7164
Practice Address - Street 1:2850 TWIN RIVERS DR
Practice Address - Street 2:
Practice Address - City:ARKADELPHIA
Practice Address - State:AR
Practice Address - Zip Code:71923-4212
Practice Address - Country:US
Practice Address - Phone:870-246-8036
Practice Address - Fax:870-246-7164
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-26
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC-1864208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5C179Medicare ID - Type Unspecified