Provider Demographics
NPI:1437118015
Name:THE GREGORY KISTLER TREATMENT CENTER, INC.
Entity type:Organization
Organization Name:THE GREGORY KISTLER TREATMENT CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:KISTLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-785-4677
Mailing Address - Street 1:3304 S M ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-2903
Mailing Address - Country:US
Mailing Address - Phone:479-785-4677
Mailing Address - Fax:479-785-4673
Practice Address - Street 1:3304 S M ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-2903
Practice Address - Country:US
Practice Address - Phone:479-785-4677
Practice Address - Fax:479-785-4673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1000679370DMedicaid
AR47953OtherBCBS DME
AR115951742Medicaid
AR117606716Medicaid
AR5B311OtherBCBS TREATMENT
OK1000679370DMedicaid