Provider Demographics
NPI:1679747513
Name:COSSATOT POLK COUNTY SENIOR CITIZENS, INC.
Entity Type:Organization
Organization Name:COSSATOT POLK COUNTY SENIOR CITIZENS, INC.
Other - Org Name:COSSATOT SENIOR CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-385-2373
Mailing Address - Street 1:7366 HIGHWAY 71 S
Mailing Address - Street 2:
Mailing Address - City:WICKES
Mailing Address - State:AR
Mailing Address - Zip Code:71973-9341
Mailing Address - Country:US
Mailing Address - Phone:870-385-2373
Mailing Address - Fax:870-385-2390
Practice Address - Street 1:7366 HIGHWAY 71 S
Practice Address - Street 2:
Practice Address - City:WICKES
Practice Address - State:AR
Practice Address - Zip Code:71973-9341
Practice Address - Country:US
Practice Address - Phone:870-385-2373
Practice Address - Fax:870-385-2390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR92733332U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332U00000XSuppliersHome Delivered Meals
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR160106753Medicaid