Provider Demographics
NPI:1265663702
Name:CITY OF FIRE COMMUNITY DEVELOPMENT, INC.
Entity Type:Organization
Organization Name:CITY OF FIRE COMMUNITY DEVELOPMENT, INC.
Other - Org Name:COVENANT KEEPERS COLLEGE PREPARATORY CHARTER SCHOOL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERINTENDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:LASHELL
Authorized Official - Last Name:TATUM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:501-682-7550
Mailing Address - Street 1:8300 GEYER SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72209-4946
Mailing Address - Country:US
Mailing Address - Phone:501-682-7550
Mailing Address - Fax:501-682-7577
Practice Address - Street 1:8300 GEYER SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72209-4946
Practice Address - Country:US
Practice Address - Phone:501-682-7550
Practice Address - Fax:501-682-7577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-31
Last Update Date:2009-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR6044700305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service