Healthcare Provider Details

I. General information

NPI: 1700051182
Provider Name (Legal Business Name): SUPERINTENDENT OF MAMMOTH SPRING SCHOOL DISTRICT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2008
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 GOLDSMITH AVE
MAMMOTH SPRING AR
72554-8045
US

IV. Provider business mailing address

PO BOX 370
MAMMOTH SPRING AR
72554-0370
US

V. Phone/Fax

Practice location:
  • Phone: 870-625-3096
  • Fax: 870-625-3609
Mailing address:
  • Phone: 870-625-3096
  • Fax: 870-625-3609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MRS. ANITA B HUMPHREYS
Title or Position: SPECIAL SERVICES COORDINATOR
Credential:
Phone: 870-625-3096