Basic Information
| Provider Information | |||||||||
| NPI: | 1609181783 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DE QUEEN MEDICAL CENTER INC | ||||||||
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| OtherOrganizationName: | DE QUEEN MEDICAL CENTER HOME HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1306 W COLLIN RAYE DR | ||||||||
| Address2: | |||||||||
| City: | DE QUEEN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 718322502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705844111 | ||||||||
| FaxNumber: | 8705844100 | ||||||||
| Practice Location | |||||||||
| Address1: | 1007 N 14TH ST | ||||||||
| Address2: | |||||||||
| City: | DE QUEEN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 71832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705840277 | ||||||||
| FaxNumber: | 8705840278 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2010 | ||||||||
| LastUpdateDate: | 08/27/2018 | ||||||||
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| AuthorizedOfficialLastName: | CAPSHEW | ||||||||
| AuthorizedOfficialFirstName: | RYAN | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8705844111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DE QUEEN MEDICAL CENTER INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | AR5043 | AR | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 191767514 | 05 | AR | MEDICAID |