1255339990 NPI number — CROSSETT HEALTH FOUNDATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255339990 NPI number — CROSSETT HEALTH FOUNDATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CROSSETT HEALTH FOUNDATION
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:
1255339990
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/24/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CROSSETT
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71635-0400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-364-5555
Provider Business Mailing Address Fax Number:
870-364-5577

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
211 PINE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CROSSETT
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71635
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-364-5555
Provider Business Practice Location Address Fax Number:
870-364-5577
Provider Enumeration Date:
07/07/2005

Additional Information

Authorized Official

Authorized Official Last Name:
CARTER
Authorized Official First Name:
TAMMY
Authorized Official Middle Name:
LEANN
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
870-364-5555

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  AR4428 , 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: 116070514 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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