Provider Demographics
NPI:1124224928
Name:JEFFERSON COMPREHENSIVE CARE SYSTEM, INC
Entity Type:Organization
Organization Name:JEFFERSON COMPREHENSIVE CARE SYSTEM, INC
Other - Org Name:REDFIELD CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LARNELL
Authorized Official - Middle Name:W
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-543-2380
Mailing Address - Street 1:PO BOX 1285
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71613-1285
Mailing Address - Country:US
Mailing Address - Phone:870-543-2380
Mailing Address - Fax:870-536-5581
Practice Address - Street 1:113 W RIVER RD
Practice Address - Street 2:
Practice Address - City:REDFIELD
Practice Address - State:AR
Practice Address - Zip Code:72132
Practice Address - Country:US
Practice Address - Phone:501-397-2261
Practice Address - Fax:501-397-2263
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JEFFERSON COMPREHENSIVE CARE SYSTEM, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-27
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR122635749Medicaid
AR122635749Medicaid