1689654337 NPI number — AREA AGENCY ON AGING OF SOUTHEAST ARKANSAS INC

Table of content: (NPI 1689654337)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689654337 NPI number — AREA AGENCY ON AGING OF SOUTHEAST ARKANSAS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AREA AGENCY ON AGING OF SOUTHEAST ARKANSAS INC
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:
Provider Other Organization Name Type Code:
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:
1689654337
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/30/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8569
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PINE BLUFF
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71611-8569
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-543-6300
Provider Business Mailing Address Fax Number:
870-534-2152

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
709 E 8TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PINE BLUFF
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71601-5010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-543-6300
Provider Business Practice Location Address Fax Number:
870-534-2152
Provider Enumeration Date:
01/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TYNES
Authorized Official First Name:
KATHY
Authorized Official Middle Name:
C
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
870-543-6300

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 103043514 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 120723765 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 128091738 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 120446752 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 120448757 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 102989732 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 146247754 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 132845715 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 120447753 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 17030 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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