Provider Demographics
NPI:1477004471
Name:MAINLINE HEALTH SYSTEMS, INC
Entity Type:Organization
Organization Name:MAINLINE HEALTH SYSTEMS, INC
Other - Org Name:DERMOTT SCHOOL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-538-5414
Mailing Address - Street 1:106 E SPEEDWAY ST
Mailing Address - Street 2:PO BOX 509
Mailing Address - City:DERMOTT
Mailing Address - State:AR
Mailing Address - Zip Code:71638-2317
Mailing Address - Country:US
Mailing Address - Phone:870-538-5414
Mailing Address - Fax:870-538-5412
Practice Address - Street 1:525 E SPEEDWAY ST
Practice Address - Street 2:
Practice Address - City:DERMOTT
Practice Address - State:AR
Practice Address - Zip Code:71638-2322
Practice Address - Country:US
Practice Address - Phone:870-538-3355
Practice Address - Fax:855-811-4203
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-14
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)