Provider Demographics
NPI:1932462504
Name:CBK KIDS R KIDS
Entity Type:Organization
Organization Name:CBK KIDS R KIDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ORBY
Authorized Official - Middle Name:GENE
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-222-4544
Mailing Address - Street 1:PO BOX 1051
Mailing Address - Street 2:
Mailing Address - City:MC GEHEE
Mailing Address - State:AR
Mailing Address - Zip Code:71654-1051
Mailing Address - Country:US
Mailing Address - Phone:870-222-4544
Mailing Address - Fax:870-222-4557
Practice Address - Street 1:1014 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EUDORA
Practice Address - State:AR
Practice Address - Zip Code:71640-2251
Practice Address - Country:US
Practice Address - Phone:870-355-0140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR26748251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR191864724Medicaid