Healthcare Provider Details

I. General information

NPI: 1508303124
Provider Name (Legal Business Name): MAINLINE HEALTH SYSTEMS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2017
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360A W HIGHWAY 82
LAKE VILLAGE AR
71653-7501
US

IV. Provider business mailing address

342 HIGHWAY 425 S
MONTICELLO AR
71655-4612
US

V. Phone/Fax

Practice location:
  • Phone: 870-201-2127
  • Fax: 888-671-8943
Mailing address:
  • Phone: 870-942-3000
  • Fax: 870-942-3005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number StateNULL

VIII. Authorized Official

Name: GARY ALLAN NICHOLS
Title or Position: CEO
Credential:
Phone: 870-942-3000