Healthcare Provider Details

I. General information

NPI: 1336482439
Provider Name (Legal Business Name): DEQUEEN MENA EDUCATIONAL COOP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2013
Last Update Date: 03/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 S HORNBERG AVENUE
GILLHAM AR
71841
US

IV. Provider business mailing address

PO BOX 110
GILLHAM AR
71841-0110
US

V. Phone/Fax

Practice location:
  • Phone: 870-386-2251
  • Fax: 870-386-7731
Mailing address:
  • Phone: 870-386-2251
  • Fax: 870-386-7731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number194666720
License Number StateAR

VIII. Authorized Official

Name: DIANA HICKS
Title or Position: EARLY CHILDHOOD COORDINATOR
Credential:
Phone: 870-386-2251