=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568890788
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTH ARKANSAS REGIONAL HEALTH CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2013
-----------------------------------------------------
Last Update Date | 10/25/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 715 N COLLEGE AVE
-----------------------------------------------------
City | EL DORADO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71730-4403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-862-7921
-----------------------------------------------------
Fax | 870-864-2490
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 715 N COLLEGE AVE
-----------------------------------------------------
City | EL DORADO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71730-4403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-862-7921
-----------------------------------------------------
Fax | 870-864-2490
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS OFFICE SUPERVISOR
-----------------------------------------------------
Name | ROBYN GRAY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 870-864-2468
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | A1309118
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------