1285655472 NPI number — STATE OF ARKANSAS

Table of content: (NPI 1285655472)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285655472 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:
Provider Other Organization Name Type Code:
6
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:
1285655472
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/10/2008
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:
501-661-2614
Provider Business Mailing Address Fax Number:
501-661-2975

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
721 WEST 1ST STREET
Provider Second Line Business Practice Location Address:
LOGAN COUNTY HEALTH UNIT
Provider Business Practice Location Address City Name:
BOONEVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72927-4567
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-675-4370
Provider Business Practice Location Address Fax Number:
479-675-5852
Provider Enumeration Date:
07/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EVANS
Authorized Official First Name:
MARILYN
Authorized Official Middle Name:
Authorized Official Title or Position:
HOME HEALTH ADMINISTRATOR
Authorized Official Telephone Number:
501-661-2540

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  AR4041 , 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: 104312514 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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