Provider Demographics
NPI:1205056595
Name:THE CLINIC FOR CHILDREN, YOUTH AND YOUNG ADULTS
Entity type:Organization
Organization Name:THE CLINIC FOR CHILDREN, YOUTH AND YOUNG ADULTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-777-7581
Mailing Address - Street 1:PO BOX 785
Mailing Address - Street 2:
Mailing Address - City:HOPE
Mailing Address - State:AR
Mailing Address - Zip Code:71802-0785
Mailing Address - Country:US
Mailing Address - Phone:870-777-7581
Mailing Address - Fax:870-777-4625
Practice Address - Street 1:820 MAIN ST S
Practice Address - Street 2:
Practice Address - City:HOPE
Practice Address - State:AR
Practice Address - Zip Code:71801
Practice Address - Country:US
Practice Address - Phone:870-777-7581
Practice Address - Fax:870-777-4625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC53912080H0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080H0002XAllopathic & Osteopathic PhysiciansPediatricsHospice and Palliative MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARD79377Medicare UPIN