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	251G00000X	Community Based Hospice Care Agency	0143	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
2	0413	OTHER	AR	AR STATE HOSPICE LICENSE

General Provider Information

NPI Number	:	1811926967
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATE OF ARKANSAS

Provider Business Mailing Address
First Line	:	5800 W 10TH ST
Second Line	:	SUITE 300
City	:	LITTLE ROCK
State	:	AR
Zip	:	72204-1752
Country	:	US
Telephone Number	:	501-661-2698
Fax Number	:	501-280-4626

Provider Business Practice Location Address
First Line	:	409 W 4TH ST
Second Line	:	MONROE COUNTY HEALTH UNITY
City	:	BRINKLEY
State	:	AR
Zip	:	72021-2113
Country	:	US
Telephone Number	:	501-661-2698
Fax Number	:	501-280-4626

Authorized Official
Title or Position	:	HOSPICE DIRECTOR
Name	:	MS. GAYLA LANUM
Credential	:	R.N.
Telephone Number	:	501-661-2698

Provider Enumeration Date	:	07/01/2006
Last Update Date	:	10/09/2012

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Directions to “STATE OF ARKANSAS ” Practice Location

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