1316172430 NPI number — CONWAY COUNTY COMMUNITY SERVICE INC.

Table of content: MISS GINA OTILIA HEREDEA P.T. (NPI 1003984451)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316172430 NPI number — CONWAY COUNTY COMMUNITY SERVICE INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONWAY COUNTY COMMUNITY SERVICE 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:
6
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:
1316172430
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1042
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DANVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72833-1042
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-495-5177
Provider Business Mailing Address Fax Number:
479-495-5187

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1408 E 8TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DANVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72833-8013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-495-5177
Provider Business Practice Location Address Fax Number:
479-495-5187
Provider Enumeration Date:
05/19/2009

Additional Information

Authorized Official

Authorized Official Last Name:
WHEAT
Authorized Official First Name:
ANGELA
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
PA/CREDENTIALING CLERK
Authorized Official Telephone Number:
501-354-4589

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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