Organization
FULL POTENTIAL
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. WANDA NELSON (BILLER)
(501) 562-5400
Entity
Organization
Contact information
Practice address
1032 SKYLINE DR, ALEXANDER, AR 72002-1749
(870) 814-5180
Mailing address
1032 SKYLINE DR, ALEXANDER, AR 72002-1749
(870) 814-5180
Taxonomy
Speciality
Code
Description
License number
State
302R00000X
Health Maintenance Organization
Primary
OT-A471
AR
Other
Enumeration date
02/16/2012
Last updated
02/16/2012
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