Provider Demographics
NPI:1437964244
Name:1621 E 42 LLC
Entity type:Organization
Organization Name:1621 E 42 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:V
Authorized Official - Last Name:HOLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-224-0846
Mailing Address - Street 1:10 SHACKLEFORD PLZ STE 102
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-1886
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1621 E 42ND ST
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-1654
Practice Address - Country:US
Practice Address - Phone:870-772-0689
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-10
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health