Provider Demographics
NPI:1992715049
Name:STATE OF ARKANSAS
Entity type:Organization
Organization Name:STATE OF ARKANSAS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HOME HEALTH ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARILYN
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:501-661-2540
Mailing Address - Street 1:5800 WEST 10TH STREET
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72204-1764
Mailing Address - Country:US
Mailing Address - Phone:501-661-2614
Mailing Address - Fax:501-661-2975
Practice Address - Street 1:1300 PACE RD
Practice Address - Street 2:RANDOLPH COUNTY HEALTH UNIT
Practice Address - City:POCAHONTAS
Practice Address - State:AR
Practice Address - Zip Code:72455-4305
Practice Address - Country:US
Practice Address - Phone:870-892-5239
Practice Address - Fax:870-892-1117
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF ARKANSAS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-09
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR4018251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR104312514Medicaid
AR047852Medicare Oscar/Certification