=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407988355
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STATE OF ARKANSAS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2007
-----------------------------------------------------
Last Update Date | 06/26/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 PRATOR DRIVE
-----------------------------------------------------
City | ARKADELPHIA
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-246-8011
-----------------------------------------------------
Fax | 870-230-8424
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 8181
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72203-8181
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-246-8011
-----------------------------------------------------
Fax | 870-230-8424
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SUPERINTENDENT
-----------------------------------------------------
Name | MS. MARGARET GREEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 870-246-8011
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320900000X
-----------------------------------------------------
Taxonomy Name | Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
-----------------------------------------------------
License Number | 320900000X
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------