Basic Information
| Provider Information | |||||||||
| NPI: | 1851546725 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THE UNITED METHODIST CHILDREN'S HOME | ||||||||
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| OtherOrganizationName: | METHODIST CHILDREN'S HOME - RTC DACUS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 ALDERSGATE RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722056676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5016610720 | ||||||||
| FaxNumber: | 5013257938 | ||||||||
| Practice Location | |||||||||
| Address1: | 211 CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | BONO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724169578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709328880 | ||||||||
| FaxNumber: | 5013257938 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2008 | ||||||||
| LastUpdateDate: | 06/01/2016 | ||||||||
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| AuthorizedOfficialLastName: | COLE | ||||||||
| AuthorizedOfficialFirstName: | LESLEY | ||||||||
| AuthorizedOfficialMiddleName: | DON | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5016610720 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 322D00000X | Y | Residential Treatment Facilities | Residential Treatment Facility, Emotionally Disturbed Children |
ID Information
| ID | Type | State | Issuer | Description | 171082125 | 05 | AR | MEDICAID |