1649501461 NPI number — WESTERN ARKANSAS COUNSELING & GUIDANCE CENTER, INC.-31ST STREET CLINIC

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 1649501461 NPI number — WESTERN ARKANSAS COUNSELING & GUIDANCE CENTER, INC.-31ST STREET CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESTERN ARKANSAS COUNSELING & GUIDANCE CENTER, INC.-31ST STREET CLINIC
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:
1649501461
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11818
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT SMITH
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72917-1818
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-452-6650
Provider Business Mailing Address Fax Number:
479-785-9495

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2100 N 31ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT SMITH
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72904-6140
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-452-6650
Provider Business Practice Location Address Fax Number:
479-785-9495
Provider Enumeration Date:
01/18/2010

Additional Information

Authorized Official

Authorized Official Last Name:
WEST
Authorized Official First Name:
JIM
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
479-452-6650

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)

  • Identifier: 181576526 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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