MEDICARE: STATE OF ARKANSAS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency	AR3984	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548270689
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATE OF ARKANSAS

Provider Business Mailing Address
First Line	:	5800 WEST 10TH STREET
Second Line	:	SUITE 300
City	:	LITTLE ROCK
State	:	AR
Zip	:	72204-1764
Country	:	US
Telephone Number	:	501-661-2614
Fax Number	:	501-661-2975

Provider Business Practice Location Address
First Line	:	201 NORTH SPRING STREET
Second Line	:	DALLAS COUNTY HEALTH UNIT
City	:	FORDYCE
State	:	AR
Zip	:	71742-3026
Country	:	US
Telephone Number	:	870-352-7197
Fax Number	:	870-352-3848

Authorized Official
Title or Position	:	HOME HEALTH ADMINISTRATOR
Name	:	MARILYN EVANS
Credential	:	RN
Telephone Number	:	501-661-2540

Provider Enumeration Date	:	08/09/2006
Last Update Date	:	05/12/2008

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Directions to “STATE OF ARKANSAS ” Practice Location

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