Healthcare Provider Details

I. General information

NPI: 1609298306
Provider Name (Legal Business Name): CB KING JM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2014
Last Update Date: 01/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 NORTH SCHOOL
DERMOTT AR
71638-0000
US

IV. Provider business mailing address

1109 NORTH SCHOOL
DERMOTT AR
71638
US

V. Phone/Fax

Practice location:
  • Phone: 870-538-9659
  • Fax:
Mailing address:
  • Phone: 870-538-9659
  • Fax: 870-538-9659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number27992
License Number StateAR

VIII. Authorized Official

Name: MR. ORBY GENE GREGORY
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 870-222-4544