Provider Demographics
NPI:1578121448
Name:FAITHFUL HEALTHCARE & SUPPLIES,LLC
Entity Type:Organization
Organization Name:FAITHFUL HEALTHCARE & SUPPLIES,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:CALLICUTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-636-9593
Mailing Address - Street 1:110 BLOCK ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:AR
Mailing Address - Zip Code:72364-1956
Mailing Address - Country:US
Mailing Address - Phone:870-636-9593
Mailing Address - Fax:
Practice Address - Street 1:110 BLOCK ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:AR
Practice Address - Zip Code:72364-1956
Practice Address - Country:US
Practice Address - Phone:870-636-9593
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-04
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR225320732Medicaid