Provider Demographics
NPI:1407988355
Name:STATE OF ARKANSAS
Entity type:Organization
Organization Name:STATE OF ARKANSAS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-246-8011
Mailing Address - Street 1:PO BOX 8181
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72203-8181
Mailing Address - Country:US
Mailing Address - Phone:870-246-8011
Mailing Address - Fax:870-230-8424
Practice Address - Street 1:1 PRATOR DRIVE
Practice Address - Street 2:
Practice Address - City:ARKADELPHIA
Practice Address - State:AR
Practice Address - Zip Code:71923
Practice Address - Country:US
Practice Address - Phone:870-246-8011
Practice Address - Fax:870-230-8424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR320900000X320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR109055213Medicaid