Provider Demographics
NPI:1730552654
Name:MEEKER, RUSTY
Entity type:Individual
Prefix:
First Name:RUSTY
Middle Name:
Last Name:MEEKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12800 CHENAL PKWY STE 7
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-3306
Mailing Address - Country:US
Mailing Address - Phone:501-221-6783
Mailing Address - Fax:
Practice Address - Street 1:12800 CHENAL PKWY STE 7
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-3306
Practice Address - Country:US
Practice Address - Phone:501-221-6783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA352305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR46-4182724Medicaid