Provider Demographics
NPI:1306011200
Name:BLACK RIVER AREA DEVELOPMENT CORP. SENIOR CITIZENS PROGRAM
Entity Type:Organization
Organization Name:BLACK RIVER AREA DEVELOPMENT CORP. SENIOR CITIZENS PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BLACK RIVER AREA DEV.
Authorized Official - Prefix:MR
Authorized Official - First Name:JIM
Authorized Official - Middle Name:
Authorized Official - Last Name:JANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-892-4547
Mailing Address - Street 1:1403 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:POCAHONTAS
Mailing Address - State:AR
Mailing Address - Zip Code:72455-3847
Mailing Address - Country:US
Mailing Address - Phone:870-892-4547
Mailing Address - Fax:870-892-0707
Practice Address - Street 1:1403 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:POCAHONTAS
Practice Address - State:AR
Practice Address - Zip Code:72455-3847
Practice Address - Country:US
Practice Address - Phone:870-892-4547
Practice Address - Fax:870-892-0707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332U00000XSuppliersHome Delivered Meals
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR120546753Medicaid