Provider Demographics
NPI:1861631723
Name:RICH MOUNTAIN WOMENS CLINIC
Entity type:Organization
Organization Name:RICH MOUNTAIN WOMENS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:MESKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-394-4595
Mailing Address - Street 1:403 MORROW ST N STE A
Mailing Address - Street 2:
Mailing Address - City:MENA
Mailing Address - State:AR
Mailing Address - Zip Code:71953-4324
Mailing Address - Country:US
Mailing Address - Phone:479-394-4595
Mailing Address - Fax:479-394-1140
Practice Address - Street 1:403 MORROW ST N STE A
Practice Address - Street 2:
Practice Address - City:MENA
Practice Address - State:AR
Practice Address - Zip Code:71953-4324
Practice Address - Country:US
Practice Address - Phone:479-394-4595
Practice Address - Fax:479-394-1140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-16
Last Update Date:2009-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC-6220174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK10071960 AMedicaid
AR112972001Medicaid
AR50764OtherBLUE CROSS BLUE SHEILD
AR50764Medicare PIN