Provider Demographics
NPI:1538170956
Name:BLYTHEVILLE CITIZENS BAND RADIO CLUB INC
Entity type:Organization
Organization Name:BLYTHEVILLE CITIZENS BAND RADIO CLUB INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:GODSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-740-2248
Mailing Address - Street 1:200 CHICKASAWBA ST
Mailing Address - Street 2:
Mailing Address - City:BLYTHEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72315-2812
Mailing Address - Country:US
Mailing Address - Phone:870-740-2248
Mailing Address - Fax:870-763-6794
Practice Address - Street 1:200 CHICKASAWBA ST
Practice Address - Street 2:
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315-2812
Practice Address - Country:US
Practice Address - Phone:870-740-2248
Practice Address - Fax:870-763-6794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR368341600000X
341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR49197Medicare ID - Type Unspecified