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	AR4008	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	:	1659381705
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	:	346 LUZERNE
Second Line	:	MONTGOMERY COUNTY HEALTH UNIT
City	:	MOUNT IDA
State	:	AR
Zip	:	71957
Country	:	US
Telephone Number	:	870-867-2331
Fax Number	:	870-867-3656

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	:	09/11/2008

Similar Medicare Providers

1225025778 — DR. ERIC E CARSON D.C.
Practice Location Address:

307 N GEORGE ST.
MOUNT IDA, AR
71957

Practice Phone: 870-867-0172
Practice Fax: 501-701-4050

1841276003 — DR. JIMMY L BARROW D.O.
Practice Location Address:

534 LUZERNE ST
MOUNT IDA, AR
71957

Practice Phone: 870-867-4244
Practice Fax: 870-867-4254

1821055195 — AREA AGENCY ON AGING OF WESTERN ARKANSAS, INC
Practice Location Address:

500 HWY 270 EAST
MOUNT IDA, AR
71957

Practice Phone: 870-867-4186
Practice Fax:

1598774465 — JACK W. WILSON DDS
Practice Location Address:

534 LUZERNE ST
MOUNT IDA, AR
71957-9449

Practice Phone: 870-867-4244
Practice Fax: 870-867-4254

1487667655 — MONTGOMERY COUNTY NURSING HOME
Practice Location Address:

741 S DR
MOUNT IDA, AR
71957-1208

Practice Phone: 870-867-2156
Practice Fax: 870-867-2049

1861585002 — CITY DRUG AND SODA FOUNTAIN
Practice Location Address:

121 W S WEST STREET
MOUNT IDA, AR
71957

Practice Phone: 870-867-3310
Practice Fax: 870-867-4848

Directions to “STATE OF ARKANSAS ” Practice Location

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