Provider Demographics
NPI:1508190273
Name:ARKANSAS SUPPORT NETWORK
Entity Type:Organization
Organization Name:ARKANSAS SUPPORT NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:VIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-927-4100
Mailing Address - Street 1:6836 ISAACS ORCHARD RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-6096
Mailing Address - Country:US
Mailing Address - Phone:479-927-4100
Mailing Address - Fax:479-927-4101
Practice Address - Street 1:6878 ISAACS ORCHARD RD
Practice Address - Street 2:SUITE B
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-6096
Practice Address - Country:US
Practice Address - Phone:479-927-4100
Practice Address - Fax:479-927-4101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-28
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR178492724Medicaid