Provider Demographics
NPI:1720017833
Name:STATE OF ARKANSAS
Entity Type:Organization
Organization Name:STATE OF ARKANSAS
Other - Org Name:ARKANSAS DEPARTMENT OF HEALTH HOSPICE 3
Other - Org Type:Doing Business As
Authorized Official - Title/Position:HOSPICE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:GAYLA
Authorized Official - Middle Name:EVETTE
Authorized Official - Last Name:LANUM
Authorized Official - Suffix:
Authorized Official - Credentials:RN BSN
Authorized Official - Phone:501-661-2698
Mailing Address - Street 1:5800 WEST 10TH ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72204-1764
Mailing Address - Country:US
Mailing Address - Phone:501-661-2698
Mailing Address - Fax:501-280-4626
Practice Address - Street 1:404 EL PASO
Practice Address - Street 2:NORTHWEST REGIONAL OFFICE
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-8737
Practice Address - Country:US
Practice Address - Phone:501-661-2698
Practice Address - Fax:501-280-4626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR3629251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARAR3629OtherAR STATE HOSPICE LICENSE
AR123489747Medicaid
ARAR3629OtherAR STATE HOSPICE LICENSE