Provider Demographics
NPI:1487781027
Name:STATE OF ARKANSAS
Entity type:Organization
Organization Name:STATE OF ARKANSAS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:HELTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-847-3506
Mailing Address - Street 1:14701 HIGHWAY 111
Mailing Address - Street 2:
Mailing Address - City:ALEXANDER
Mailing Address - State:AR
Mailing Address - Zip Code:72002-1742
Mailing Address - Country:US
Mailing Address - Phone:501-847-3506
Mailing Address - Fax:501-847-3688
Practice Address - Street 1:14701 HIGHWAY 111
Practice Address - Street 2:
Practice Address - City:ALEXANDER
Practice Address - State:AR
Practice Address - Zip Code:72002-1742
Practice Address - Country:US
Practice Address - Phone:501-847-3506
Practice Address - Fax:501-847-3688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR138315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR109053213Medicaid