Provider Demographics
NPI:1386770030
Name:STATE PF ARKANSAS
Entity type:Organization
Organization Name:STATE PF ARKANSAS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:THERESIA
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:KEITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-932-4043
Mailing Address - Street 1:4701 COLONY DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-9317
Mailing Address - Country:US
Mailing Address - Phone:870-932-4043
Mailing Address - Fax:870-932-4459
Practice Address - Street 1:4701 COLONY DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72404-9317
Practice Address - Country:US
Practice Address - Phone:870-932-4043
Practice Address - Fax:870-932-4459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR137320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR109054213Medicaid