Provider Demographics
NPI:1609298306
Name:CB KING JM
Entity type:Organization
Organization Name:CB KING JM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ORBY
Authorized Official - Middle Name:GENE
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-222-4544
Mailing Address - Street 1:1109 NORTH SCHOOL
Mailing Address - Street 2:
Mailing Address - City:DERMOTT
Mailing Address - State:AR
Mailing Address - Zip Code:71638
Mailing Address - Country:US
Mailing Address - Phone:870-538-9659
Mailing Address - Fax:870-538-9659
Practice Address - Street 1:1109 NORTH SCHOOL
Practice Address - Street 2:
Practice Address - City:DERMOTT
Practice Address - State:AR
Practice Address - Zip Code:71638-0000
Practice Address - Country:US
Practice Address - Phone:870-538-9659
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR27992251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR19554724Medicaid