Organization
TWIN LAKES PHYSICIAN GROUP PA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. RICHARD SANDVOS (CEO)
(870) 425-6212
Entity
Organization
Contact information
Practice address
17 MEDICAL PLAZA, MOUNTAIN HOME, AR 72653
(870) 425-6212
(870) 508-6896
Mailing address
17 MEDICAL PLAZA, MOUNTAIN HOME, AR 72653
(870) 425-6212
(870) 508-6896
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
—
—
207Q00000X
Family Medicine Physician
—
—
207R00000X
Internal Medicine Physician
—
—
208D00000X
General Practice Physician
Primary
—
—
208VP0000X
Pain Medicine Physician
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
184075002
—
AR
01
—
5G314
AR BC/BS
AR
01
—
DQ7170
RAILROAD MEDICARE
AR
Enumeration date
08/02/2010
Last updated
08/16/2013
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