Provider Demographics
NPI:1366933855
Name:YOUR BARIATRIC CARE CLINIC EA
Entity type:Organization
Organization Name:YOUR BARIATRIC CARE CLINIC EA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUCKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-663-9600
Mailing Address - Street 1:1 SAINT VINCENT CIR STE 320
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5408
Mailing Address - Country:US
Mailing Address - Phone:501-663-9600
Mailing Address - Fax:501-217-8502
Practice Address - Street 1:1 SAINT VINCENT CIR STE 320
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5408
Practice Address - Country:US
Practice Address - Phone:501-663-9600
Practice Address - Fax:501-217-8502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-21
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-7393207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1558330431OtherNPI