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General NPI Number Information
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NPI Number | 1720017833
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Entity Type | Organization
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Legal Business Name | STATE OF ARKANSAS
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Dates
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Enumeration Date | 07/01/2006
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Last Update Date | 10/09/2012
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Provider Practice Location Address
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Address Line | 404 EL PASO NORTHWEST REGIONAL OFFICE
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City | RUSSELLVILLE
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State | AR
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Zip | 72801-8737
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Country | US
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Telephone | 501-661-2698
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Fax | 501-280-4626
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Provider Business Mailing Address
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Address Line | 5800 WEST 10TH ST SUITE 300
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City | LITTLE ROCK
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State | AR
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Zip | 72204-1764
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Country | US
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Telephone | 501-661-2698
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Fax | 501-280-4626
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Authorized Official
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Title or Position | HOSPICE DIRECTOR
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Name | MS. GAYLA EVETTE LANUM
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Credential | R.N. BSN
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Telephone | 501-661-2698
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251G00000X
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Taxonomy Name | Community Based Hospice Care Agency
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License Number | AR3629
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License Number State | AR
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