Provider Demographics
NPI:1801928627
Name:STATE OF ARKANSAS
Entity type:Organization
Organization Name:STATE OF ARKANSAS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:STOREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-675-1411
Mailing Address - Street 1:87 REED RD
Mailing Address - Street 2:HIGHWAY 116 SOUTH
Mailing Address - City:BOONEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72927
Mailing Address - Country:US
Mailing Address - Phone:479-675-2121
Mailing Address - Fax:479-675-5820
Practice Address - Street 1:87 REED RD
Practice Address - Street 2:HIGHWAY 116 SOUTH
Practice Address - City:BOONEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72927
Practice Address - Country:US
Practice Address - Phone:479-675-2121
Practice Address - Fax:479-675-5820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR109051213Medicaid