NPIMap

Organization Active NPI

De Queen Medical Center Dialysis

  • End-Stage Renal Disease (ESRD) Treatment Clinic/Center
  • De Queen, AR
National Provider Identifier
1104356419
Registry record updated Jul 21, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
End-Stage Renal Disease (ESRD) Treatment Clinic/CenterTaxonomy code 261QE0700X
Legal business name
DE QUEEN MEDICAL CENTER DIALYSIS
Practice address
1306 W Collin Raye Dr
De Queen, AR 71832-2502
Phone
(870) 584-4111
Fax
(870) 584-4100
NPI assigned
Jun 19, 2017
Organization subpart
Yes
Parent organization
DE QUEEN MEDICAL CENTER, INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jul 21, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Jerramy Icenhower
Title
Administrator
Phone
(870) 584-0272

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
End-Stage Renal Disease (ESRD) Treatment Clinic/Center 261QE0700X Primary

Addresses

Primary practice location

1306 W Collin Raye Dr
De Queen, AR 71832-2502

Mailing address

1306 W Collin Raye Dr
De Queen, AR 71832-2502
Phone (870) 584-4111

National Provider Directory

National Provider Directory
Tax ID family
De Queen Medical Center Inc3 organizations share this tax ID, including this one
Part of
De Queen Medical Center Inc

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1497830400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1658361600000",
    "number": "1104356419",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1306 W COLLIN RAYE DR",
            "city": "DE QUEEN",
            "state": "AR",
            "postal_code": "718322502",
            "telephone_number": "870-584-4111",
            "fax_number": "870-584-4100"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1306 W COLLIN RAYE DR",
            "city": "DE QUEEN",
            "state": "AR",
            "postal_code": "718322502",
            "telephone_number": "870-584-4111",
            "fax_number": "870-584-4100"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "DE QUEEN MEDICAL CENTER DIALYSIS",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "DE QUEEN MEDICAL CENTER, INC",
        "enumeration_date": "2017-06-19",
        "last_updated": "2022-07-21",
        "status": "A",
        "authorized_official_last_name": "ICENHOWER",
        "authorized_official_first_name": "JERRAMY",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "870-584-0272",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "261QE0700X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, End-Stage Renal Disease (ESRD) Treatment",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in De Queen, AR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 21, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.