Healthcare Provider Details

I. General information

NPI: 1437960929
Provider Name (Legal Business Name): MAINLINE HEALTH SYSTEMS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2025
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 MAIN ST
RISON AR
71665-9563
US

IV. Provider business mailing address

PO BOX 509
DERMOTT AR
71638-0509
US

V. Phone/Fax

Practice location:
  • Phone: 870-325-6255
  • Fax: 870-325-6117
Mailing address:
  • Phone: 870-942-3000
  • Fax: 870-538-5412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: ELYSE KNOBLOCH
Title or Position: CHIEF FINANCIAL OFFICER
Credential: CPA
Phone: 870-942-3000