1508917295 NPI number — CIVITAN CENTER

Table of content: (NPI 1508917295)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508917295 NPI number — CIVITAN CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CIVITAN CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CIVITAN SERVICES
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508917295
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
121 SOUTH COX STREET
Provider Second Line Business Mailing Address:
P. O. BOX 368
Provider Business Mailing Address City Name:
BENTON
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72018-0368
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-776-0691
Provider Business Mailing Address Fax Number:
501-776-0692

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
121 SOUTH COX STREET
Provider Second Line Business Practice Location Address:
121 SOUTH COX STREET
Provider Business Practice Location Address City Name:
BENTON
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72018-0368
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-776-0691
Provider Business Practice Location Address Fax Number:
501-776-0692
Provider Enumeration Date:
01/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HENDERSON
Authorized Official First Name:
LEAH
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
501-776-0691

Provider Taxonomy Codes

  • Taxonomy code: 251C00000X , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 105505724 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 120140715 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 116454742 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 131841774 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 125972767 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 132537786 . This is a "STATE NONMEDICAID" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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