Provider Demographics
NPI:1962637082
Name:CONWAY COUNTY COMMUNITY SERVICE INC
Entity Type:Organization
Organization Name:CONWAY COUNTY COMMUNITY SERVICE INC
Other - Org Name:COMMUNITY SERVICE INC. - CLINTON
Other - Org Type:Other Name
Authorized Official - Title/Position:PA/CREDENTIALING CLERK
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WHEAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-354-4589
Mailing Address - Street 1:P.O. BOX 1133
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:AR
Mailing Address - Zip Code:72031
Mailing Address - Country:US
Mailing Address - Phone:501-745-2956
Mailing Address - Fax:501-745-2956
Practice Address - Street 1:119 SHAKE RAG RD
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:AR
Practice Address - Zip Code:72031-6682
Practice Address - Country:US
Practice Address - Phone:501-745-2956
Practice Address - Fax:501-745-6918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-19
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health