Healthcare Provider Details

I. General information

NPI: 1245005115
Provider Name (Legal Business Name): MAINLINE HEALTH SYSTEMS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2023
Last Update Date: 11/20/2023
Certification Date: 11/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2018 LADY JACK DRIVE
WARREN AR
71638
US

IV. Provider business mailing address

PO BOX 509
DERMOTT AR
71638-0509
US

V. Phone/Fax

Practice location:
  • Phone: 870-466-8450
  • Fax: 877-456-0923
Mailing address:
  • Phone: 870-538-5414
  • Fax: 870-538-5412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TAFTA MCCAIN
Title or Position: CFO
Credential:
Phone: 870-538-5414