Healthcare Provider Details

I. General information

NPI: 1659381705
Provider Name (Legal Business Name): STATE OF ARKANSAS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 09/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

346 LUZERNE MONTGOMERY COUNTY HEALTH UNIT
MOUNT IDA AR
71957
US

IV. Provider business mailing address

5800 WEST 10TH STREET SUITE 300
LITTLE ROCK AR
72204-1764
US

V. Phone/Fax

Practice location:
  • Phone: 870-867-2331
  • Fax: 870-867-3656
Mailing address:
  • Phone: 501-661-2614
  • Fax: 501-661-2975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberAR4008
License Number StateAR

VIII. Authorized Official

Name: MARILYN EVANS
Title or Position: HOME HEALTH ADMINISTRATOR
Credential: RN
Phone: 501-661-2540