Provider Demographics
NPI:1104216324
Name:BENTON COUNTY COMMISSION ON AGING AND INDEPENDEN LIVING
Entity Type:Organization
Organization Name:BENTON COUNTY COMMISSION ON AGING AND INDEPENDEN LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CARL
Authorized Official - Middle Name:LATRON
Authorized Official - Last Name:ROBINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-441-9900
Mailing Address - Street 1:1342 COUNTRY CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:LAMAR
Mailing Address - State:MS
Mailing Address - Zip Code:38642
Mailing Address - Country:US
Mailing Address - Phone:949-441-9900
Mailing Address - Fax:
Practice Address - Street 1:1342 COUNTRY CHURCH RD
Practice Address - Street 2:
Practice Address - City:LAMAR
Practice Address - State:MS
Practice Address - Zip Code:38642
Practice Address - Country:US
Practice Address - Phone:949-441-9900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-26
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care