Provider Demographics
NPI:1336482439
Name:DEQUEEN MENA EDUCATIONAL COOP
Entity Type:Organization
Organization Name:DEQUEEN MENA EDUCATIONAL COOP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EARLY CHILDHOOD COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-386-2251
Mailing Address - Street 1:PO BOX 110
Mailing Address - Street 2:
Mailing Address - City:GILLHAM
Mailing Address - State:AR
Mailing Address - Zip Code:71841-0110
Mailing Address - Country:US
Mailing Address - Phone:870-386-2251
Mailing Address - Fax:870-386-7731
Practice Address - Street 1:305 S HORNBERG AVENUE
Practice Address - Street 2:
Practice Address - City:GILLHAM
Practice Address - State:AR
Practice Address - Zip Code:71841
Practice Address - Country:US
Practice Address - Phone:870-386-2251
Practice Address - Fax:870-386-7731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-27
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR194666720251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR194666720Medicaid