Provider Demographics
NPI:1053637074
Name:CB KING INFANT CENTER
Entity Type:Organization
Organization Name:CB KING INFANT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:J
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-222-4544
Mailing Address - Street 1:1610 S 1ST ST
Mailing Address - Street 2:P.O. BOX 1051
Mailing Address - City:MC GEHEE
Mailing Address - State:AR
Mailing Address - Zip Code:71654-2908
Mailing Address - Country:US
Mailing Address - Phone:870-222-4544
Mailing Address - Fax:870-222-4550
Practice Address - Street 1:1610 S 1ST ST
Practice Address - Street 2:1610 S 1ST ST
Practice Address - City:MC GEHEE
Practice Address - State:AR
Practice Address - Zip Code:71654-2908
Practice Address - Country:US
Practice Address - Phone:870-222-4544
Practice Address - Fax:870-222-4550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-15
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR01923261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR180547724Medicaid