Provider Demographics
NPI:1982911798
Name:SELECT MEDICAL SUPPLIES OF ARKANSAS, INC.
Entity Type:Organization
Organization Name:SELECT MEDICAL SUPPLIES OF ARKANSAS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:OLGA
Authorized Official - Middle Name:
Authorized Official - Last Name:WESSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-562-8007
Mailing Address - Street 1:24 SOUTHPARK SHOPPING CTR
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:71852-3307
Mailing Address - Country:US
Mailing Address - Phone:870-845-3813
Mailing Address - Fax:870-845-3808
Practice Address - Street 1:24 SOUTHPARK SHOPPING CTR
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:AR
Practice Address - Zip Code:71852-3307
Practice Address - Country:US
Practice Address - Phone:870-845-3813
Practice Address - Fax:870-845-3808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-01
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMG01007332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR189835716Medicaid
AR4T128OtherBCBS
AR189835716Medicaid