Provider Demographics
NPI:1952405524
Name:MAINLINE HEALTH SYSTEMS, INC
Entity type:Organization
Organization Name:MAINLINE HEALTH SYSTEMS, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-538-5414
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:AR
Mailing Address - Zip Code:71663-0100
Mailing Address - Country:US
Mailing Address - Phone:870-737-2737
Mailing Address - Fax:870-737-9780
Practice Address - Street 1:203 MCCOMB ST
Practice Address - Street 2:
Practice Address - City:WILMOT
Practice Address - State:AR
Practice Address - Zip Code:71676
Practice Address - Country:US
Practice Address - Phone:870-473-2274
Practice Address - Fax:870-473-5392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR112127631Medicaid