Provider Demographics
NPI:1508917295
Name:CIVITAN CENTER
Entity Type:Organization
Organization Name:CIVITAN CENTER
Other - Org Name:CIVITAN SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:L
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSE-ECSE
Authorized Official - Phone:501-776-0691
Mailing Address - Street 1:121 SOUTH COX STREET
Mailing Address - Street 2:P. O. BOX 368
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72018-0368
Mailing Address - Country:US
Mailing Address - Phone:501-776-0691
Mailing Address - Fax:501-776-0692
Practice Address - Street 1:121 SOUTH COX STREET
Practice Address - Street 2:121 SOUTH COX STREET
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72018-0368
Practice Address - Country:US
Practice Address - Phone:501-776-0691
Practice Address - Fax:501-776-0692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2014-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR105505724Medicaid
AR120140715Medicaid
AR116454742Medicaid
AR131841774Medicaid
AR125972767Medicaid
AR132537786OtherSTATE NONMEDICAID