Provider Demographics
NPI:1164232310
Name:THE IMAGINATION STATION LLC
Entity type:Organization
Organization Name:THE IMAGINATION STATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-818-7190
Mailing Address - Street 1:230 TIDWELL ST
Mailing Address - Street 2:
Mailing Address - City:STEPHENS
Mailing Address - State:AR
Mailing Address - Zip Code:71764-8354
Mailing Address - Country:US
Mailing Address - Phone:870-818-7190
Mailing Address - Fax:
Practice Address - Street 1:3286 W HILLSBORO ST STE A
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-6734
Practice Address - Country:US
Practice Address - Phone:870-818-7190
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-09
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services