Provider Demographics
NPI:1730425448
Name:FACE 2 FACE PLLC
Entity type:Organization
Organization Name:FACE 2 FACE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:BRONISTE
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:479-208-3471
Mailing Address - Street 1:PO BOX 140
Mailing Address - Street 2:
Mailing Address - City:LAVACA
Mailing Address - State:AR
Mailing Address - Zip Code:72941-0140
Mailing Address - Country:US
Mailing Address - Phone:479-674-9181
Mailing Address - Fax:479-674-8105
Practice Address - Street 1:1306 SYLVAN HILLS RD
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956-2565
Practice Address - Country:US
Practice Address - Phone:479-208-3471
Practice Address - Fax:888-987-1841
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-27
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR198286004Medicaid
5AH17Medicare PIN