1679860308 NPI number — EAST ARKANSAS SUBSTANCE ABUSE PROGRAM

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 1679860308 NPI number — EAST ARKANSAS SUBSTANCE ABUSE PROGRAM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST ARKANSAS SUBSTANCE ABUSE PROGRAM
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:
1679860308
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/01/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2426 HIGHWAY 49
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST HELENA
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72390-9562
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-572-3733
Provider Business Mailing Address Fax Number:
870-572-3785

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2426 HIGHWAY 49
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST HELENA
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72390-9562
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-572-3733
Provider Business Practice Location Address Fax Number:
870-572-3785
Provider Enumeration Date:
07/01/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MOORE
Authorized Official First Name:
NADA
Authorized Official Middle Name:
NIX
Authorized Official Title or Position:
COUNSELOR IN TRAINING
Authorized Official Telephone Number:
870-572-3733

Provider Taxonomy Codes

  • Taxonomy code: 324500000X , with the licence number:  CIT , 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)





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