1417986555 NPI number — STATE OF ARKANSAS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417986555 NPI number — STATE OF ARKANSAS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATE OF ARKANSAS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ARKANSAS DEPARTMENT OF HEALTH HOSPICE 6
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417986555
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5800 W 10TH ST
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72204-1752
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-661-2698
Provider Business Mailing Address Fax Number:
501-280-4626

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
207 S JEFFERSON
Provider Second Line Business Practice Location Address:
COLUMBIA COUNTY HEALTH UNIT
Provider Business Practice Location Address City Name:
MAGNOLIA
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71753-3901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-661-2698
Provider Business Practice Location Address Fax Number:
501-280-4626
Provider Enumeration Date:
07/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LANUM
Authorized Official First Name:
GAYLA
Authorized Official Middle Name:
Authorized Official Title or Position:
HOSPICE DIRECTOR
Authorized Official Telephone Number:
501-661-9628

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X , with the licence number:  AR3636 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 123489747 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: AR3606 . This is a "AR STATE HOPSICE LICENSE" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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