Provider Demographics
NPI:1225217243
Name:DEBRA FAULKNER
Entity type:Organization
Organization Name:DEBRA FAULKNER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:FAULKNER
Authorized Official - Suffix:
Authorized Official - Credentials:RT
Authorized Official - Phone:870-862-2000
Mailing Address - Street 1:532 W FAULKNER ST
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730-4519
Mailing Address - Country:US
Mailing Address - Phone:870-862-2000
Mailing Address - Fax:
Practice Address - Street 1:532 W FAULKNER ST
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-4519
Practice Address - Country:US
Practice Address - Phone:870-862-2000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-26
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR140983710Medicaid
AR19820Medicare PIN