NPIMap

Organization Active NPI

Mainline Health Systems, Inc

  • Federally Qualified Health Center (FQHC)
  • Lake Village, AR
National Provider Identifier
1508303124
Registry record updated Mar 23, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Federally Qualified Health Center (FQHC)Taxonomy code 261QF0400X
Legal business name
MAINLINE HEALTH SYSTEMS, INC
Practice address
360A W Highway 82
Lake Village, AR 71653-7501
Phone
(870) 201-2127
Fax
(888) 671-8943
NPI assigned
Jan 20, 2017
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 23, 2026

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Gary Allan Nichols
Title
Ceo
Phone
(870) 942-3000

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Cognitive & Behavioral PsychologistGroup: 193200000X MULTI-SPECIALTY GROUP 103TB0200X
Federally Qualified Health Center (FQHC) 261QF0400X Primary

Addresses

Primary practice location

360A W Highway 82
Lake Village, AR 71653-7501

Mailing address

342 Highway 425 S
Monticello, AR 71655-4612
Phone (870) 942-3000

Other identifiers 1

IdentifierTypeStateIssuer
223565749MedicaidAR

Other names 1

  • Lakeside School Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AR

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20171109000593 AR Part A Provider - Federally Qualified Health Center (FQHC) 5193785590 Practice locations: Lake Village, AR

Federally qualified health center certification: CCN 041934

Legal name
MAINLINE HEALTH SYSTEMS INC
Doing business as
LAKESIDE SCHOOL
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 8, 2017
Last certification
Nov 8, 2017
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Jul 1, 1978 in AR
Enrollment address
360A W Highway 82
Lake Village, AR 71653-7501

National Provider Directory

National Provider Directory
Tax ID family
Sanyasi R Ganta MD34 organizations share this tax ID, including this one

Other organizations with this tax ID 33

Organizations that report the same tax identification number in the National Provider Directory.

View all 33

Ownership & related parties

All disclosed owners & managing parties 13

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Gary Nichols Individual Corporate DirectorExecutive Director Sep 1, 2009
W-2 Managing EmployeeExecutive Director Sep 1, 2009
Ron Miller Individual Corporate DirectorBoard Member Jan 1, 2009
Robert Thomas Individual Corporate DirectorBoard Member Jan 1, 1997
Brandi Poole Individual Corporate OfficerExecutive Board Recruitment Chair Jan 1, 2018
Alicia Whitaker Individual Corporate OfficerChairman Executive Jan 1, 2018
Mainline Health Systems Inc Organization, Dermott, AR Non-profit Operational/Managerial Control Mar 1, 2017 100%
Mary Hollins Scott Individual Corporate DirectorBoard Member Jan 1, 1997
Keith Shepherd Individual Corporate DirectorBoard Member Jan 1, 2016
Eugene Butler Individual Corporate DirectorBoard Member Jan 1, 2013
Becky Philips Individual Corporate OfficerTreasurer Finance Chair Executive Jan 1, 2019
Elyse Knobloch Individual Operational/Managerial ControlAuthorized Official Aug 14, 2023
Michelle Dunbar Individual Corporate DirectorBoard Member Jan 1, 2013
Shanna Knowles Individual Corporate OfficerPersonnel Finance Jan 1, 2020

All facility ownership & control disclosures 25

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Monticello Community Health CenterMonticello, AR, CCN 041875 Federally qualified health center Operational/Managerial Control Jul 1, 2010
Portland Elementary ClinicPortland, AR, CCN 041917 Federally qualified health center Operational/Managerial Control (100%) Jan 11, 2016
Hamburg ElementartyHamburg, AR, CCN 041918 Federally qualified health center Operational/Managerial Control (100%) Jan 11, 2016
Mainline Health Systems IncHamburg, AR, CCN 041919 Federally qualified health center Operational/Managerial Control (100%) Jan 11, 2016
Star City Community Health CenterStar City, AR, CCN 041921 Federally qualified health center Operational/Managerial Control (100%) Dec 1, 2013
Dermott School ClinicDermott, AR, CCN 041922 Federally qualified health center Operational/Managerial Control (100%) Aug 17, 2016
Star City High School ClinicStar City, AR, CCN 041923 Federally qualified health center Operational/Managerial Control (100%) Jan 1, 2017
Jimmy Brown ElementaryStar City, AR, CCN 041926 Federally qualified health center Operational/Managerial Control (100%) Apr 4, 2017
Eudora Elementary ClinicEudora, AR, CCN 041933 Federally qualified health center Operational/Managerial Control (100%) Apr 1, 2017
Drew Central SchoolMonticello, AR, CCN 041935 Federally qualified health center Operational/Managerial Control (100%) Aug 14, 2017
Hamburg Middle SchoolHamburg, AR, CCN 041945 Federally qualified health center Operational/Managerial Control (100%) Sep 20, 2018
Mainline Health Systems IncRison, AR, CCN 041953 Federally qualified health center Operational/Managerial Control (100%) Dec 26, 2018
Warren 2Warren, AR, CCN 041966 Federally qualified health center Operational/Managerial Control (100%) Jan 2, 2020
Mainline Health Systems IncMonticello, AR, CCN 041005 Federally qualified health center 5% Or Greater Direct Ownership Interest
5% Or Greater Security Interest
Operational/Managerial Control		 Oct 1, 2021
Oct 1, 2021
Oct 1, 2021
Mainline Uam Medical ClinicMonticello, AR, CCN 041006 Federally qualified health center 5% Or Greater Direct Ownership Interest
5% Or Greater Security Interest
Operational/Managerial Control		 Oct 1, 2021
Oct 1, 2021
Oct 1, 2021
Sheridan SchoolSheridan, AR, CCN 041008 Federally qualified health center 5% Or Greater Direct Ownership Interest
5% Or Greater Security Interest
Operational/Managerial Control		 Apr 1, 2022
Apr 1, 2022
Apr 1, 2022
Sheridan Medical ClinicSheridan, AR, CCN 041009 Federally qualified health center 5% Or Greater Direct Ownership Interest
5% Or Greater Security Interest
Operational/Managerial Control		 Apr 1, 2022
Apr 1, 2022
Apr 1, 2022
Warren Middle School BHWarren, AR, CCN 041013 Federally qualified health center 5% Or Greater Direct Ownership Interest
5% Or Greater Security Interest
Operational/Managerial Control		 Jul 13, 2022
Jul 13, 2022
Jul 13, 2022
Warren High School BH (Seabec)Warren, AR, CCN 041019 Federally qualified health center Operational/Managerial Control Aug 15, 2022
Mainline Health Systems IncWarren, AR, CCN 041025 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Aug 15, 2022
Aug 15, 2022
Brunson Elementary SchoolWarren, AR, CCN 041015 Federally qualified health center 5% Or Greater Direct Ownership Interest
5% Or Greater Security Interest
Operational/Managerial Control		 Jul 13, 2022
Jul 13, 2022
Jul 13, 2022
Sheridan East EndLittle Rock, AR, CCN 041023 Federally qualified health center 5% Or Greater Direct Ownership Interest
Operational/Managerial Control		 Aug 15, 2022
Aug 15, 2022
Warren ElementaryWarren, AR, CCN 041033 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control (100%)		 Jun 26, 2023
Jun 26, 2023
Lake Village OB ClinicLake Village, AR, CCN 041047 Federally qualified health center 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control		 Jul 3, 2023
Jul 3, 2023
Cleveland County School District Health CenterRison, AR, CCN 041084 Federally qualified health center Operational/Managerial Control (100%) Aug 14, 2017

Facilities with the same owner 25

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 25

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1484870400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1774224000000",
    "number": "1508303124",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "342 HIGHWAY 425 S",
            "city": "MONTICELLO",
            "state": "AR",
            "postal_code": "716554612",
            "telephone_number": "870-942-3000",
            "fax_number": "870-942-3005"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "360A W HIGHWAY 82",
            "city": "LAKE VILLAGE",
            "state": "AR",
            "postal_code": "716537501",
            "telephone_number": "870-201-2127",
            "fax_number": "888-671-8943"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MAINLINE HEALTH SYSTEMS, INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-01-20",
        "last_updated": "2026-03-23",
        "certification_date": "2026-03-23",
        "status": "A",
        "authorized_official_last_name": "NICHOLS",
        "authorized_official_first_name": "GARY",
        "authorized_official_middle_name": "ALLAN",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "870-942-3000"
    },
    "taxonomies": [
        {
            "code": "103TB0200X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychologist, Cognitive & Behavioral",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "223565749",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lakeside School",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Lakeside School",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Lake Village, AR

Sources for this page

Verify at the official NPI Registry.