Provider Demographics
NPI:1093840282
Name:STATE OF ARKANSAS
Entity type:Organization
Organization Name:STATE OF ARKANSAS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:
Authorized Official - Last Name:SELLERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-329-6851
Mailing Address - Street 1:150 SIEBENMORGEN RD
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032
Mailing Address - Country:US
Mailing Address - Phone:501-329-6851
Mailing Address - Fax:501-336-0508
Practice Address - Street 1:150 SIEBENMORGEN RD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032
Practice Address - Country:US
Practice Address - Phone:501-329-6851
Practice Address - Fax:501-336-0508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR139320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR109217213Medicaid