Provider Demographics
NPI:1992708804
Name:COUNTY OF LOGAN
Entity type:Organization
Organization Name:COUNTY OF LOGAN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:A
Authorized Official - Last Name:FAIRBANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-963-2723
Mailing Address - Street 1:PO BOX 467
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:AR
Mailing Address - Zip Code:72855-0467
Mailing Address - Country:US
Mailing Address - Phone:479-963-2723
Mailing Address - Fax:479-963-8355
Practice Address - Street 1:310 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:AR
Practice Address - Zip Code:72855-3328
Practice Address - Country:US
Practice Address - Phone:479-963-2723
Practice Address - Fax:479-963-8355
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF LOGAN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-05-24
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR7303416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR590083475OtherRAILROAD MEDICARE
AR864525OtherFEDERAL BLACK LUNG PROGRA
AR103244715Medicaid
AR47218OtherBLUE CROSS BLUE SHIELD
AR864525OtherFEDERAL BLACK LUNG PROGRA