Provider Demographics
NPI:1447461900
Name:SOUTH LOGAN FAMILY PRACTICE
Entity type:Organization
Organization Name:SOUTH LOGAN FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:ARENDALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-675-2228
Mailing Address - Street 1:PO BOX 1373
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72927-0301
Mailing Address - Country:US
Mailing Address - Phone:479-675-2228
Mailing Address - Fax:479-675-2274
Practice Address - Street 1:1808 EAST MAIN
Practice Address - Street 2:
Practice Address - City:BOONEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72927-1373
Practice Address - Country:US
Practice Address - Phone:479-675-2228
Practice Address - Fax:479-675-2274
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE3514207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty