Provider Demographics
NPI:1538267414
Name:CLINICAL NEUROSCIENCE ASSOCIATES, INC.
Entity type:Organization
Organization Name:CLINICAL NEUROSCIENCE ASSOCIATES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:M
Authorized Official - Last Name:GUSTAFSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-434-2743
Mailing Address - Street 1:7009 NAPLES WAY
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72916-8701
Mailing Address - Country:US
Mailing Address - Phone:479-434-2743
Mailing Address - Fax:844-454-8351
Practice Address - Street 1:320 N GREENWOOD AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-3454
Practice Address - Country:US
Practice Address - Phone:479-434-2743
Practice Address - Fax:844-454-8351
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65943722Medicaid
9702Medicare ID - Type Unspecified