1043461510 NPI number — NORTHEAST ARKANSAS COMMUNITY MENTAL HEALTH CENTER INC

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 1043461510 NPI number — NORTHEAST ARKANSAS COMMUNITY MENTAL HEALTH CENTER INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST ARKANSAS COMMUNITY MENTAL HEALTH CENTER INC
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:
MID SOUTH HEALTH SYSTEMS, INC.
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:
1043461510
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2707 BROWNS LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JONESBORO
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72401-7213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-972-4000
Provider Business Mailing Address Fax Number:
870-972-4968

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
209 S LOCKARD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLYTHEVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72315-2541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-763-2139
Provider Business Practice Location Address Fax Number:
870-972-4911
Provider Enumeration Date:
10/02/2008

Additional Information

Authorized Official

Authorized Official Last Name:
JONES
Authorized Official First Name:
CARLA
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
870-972-4900

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 172110526 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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