Provider Demographics
NPI:1679640148
Name:ALLERGY & ASTHMA CLINIC OF NORTHWEST ARKANSAS
Entity type:Organization
Organization Name:ALLERGY & ASTHMA CLINIC OF NORTHWEST ARKANSAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TINA
Authorized Official - Middle Name:K
Authorized Official - Last Name:MERRITT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-254-9777
Mailing Address - Street 1:1900 S WALTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-6755
Mailing Address - Country:US
Mailing Address - Phone:479-254-9777
Mailing Address - Fax:479-254-9729
Practice Address - Street 1:1900 S WALTON BLVD
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-6755
Practice Address - Country:US
Practice Address - Phone:479-254-9777
Practice Address - Fax:479-254-9729
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE 2999174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR155052002Medicaid
AR5F153Medicare ID - Type Unspecified