1972560050 NPI number — AREA AGENCY ON AGING OF WESTERN ARKANSAS, INC

Table of content: LACRESHA ELLIS (NPI 1942876966)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972560050 NPI number — AREA AGENCY ON AGING OF WESTERN ARKANSAS, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AREA AGENCY ON AGING OF WESTERN 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:
1972560050
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
524 GARRISON AVE
Provider Second Line Business Mailing Address:
PO BOX 1724
Provider Business Mailing Address City Name:
FORT SMITH
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72901-2514
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102 BOLAN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HARTFORD
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72938
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-639-2997
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
RUSHING
Authorized Official First Name:
LISA
Authorized Official Middle Name:
Authorized Official Title or Position:
SUPERVISOR OF CORPORATE SERVICES
Authorized Official Telephone Number:
479-783-4500

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X , with the licence number:  0176 , 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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