Provider Demographics
NPI:1700051182
Name:SUPERINTENDENT OF MAMMOTH SPRING SCHOOL DISTRICT
Entity Type:Organization
Organization Name:SUPERINTENDENT OF MAMMOTH SPRING SCHOOL DISTRICT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPECIAL SERVICES COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:B
Authorized Official - Last Name:HUMPHREYS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-625-3096
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:MAMMOTH SPRING
Mailing Address - State:AR
Mailing Address - Zip Code:72554-0370
Mailing Address - Country:US
Mailing Address - Phone:870-625-3096
Mailing Address - Fax:870-625-3609
Practice Address - Street 1:410 GOLDSMITH AVE
Practice Address - Street 2:
Practice Address - City:MAMMOTH SPRING
Practice Address - State:AR
Practice Address - Zip Code:72554-8045
Practice Address - Country:US
Practice Address - Phone:870-625-3096
Practice Address - Fax:870-625-3609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR166891761Medicaid
AR166913732Medicaid
AR140932742Medicaid