Provider Demographics
NPI:1316172430
Name:CONWAY COUNTY COMMUNITY SERVICE INC.
Entity type:Organization
Organization Name:CONWAY COUNTY COMMUNITY SERVICE INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PA/CREDENTIALING CLERK
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WHEAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-354-4589
Mailing Address - Street 1:PO BOX 1042
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72833-1042
Mailing Address - Country:US
Mailing Address - Phone:479-495-5177
Mailing Address - Fax:479-495-5187
Practice Address - Street 1:1408 E 8TH ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:AR
Practice Address - Zip Code:72833-8013
Practice Address - Country:US
Practice Address - Phone:479-495-5177
Practice Address - Fax:479-495-5187
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-19
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health