Provider Demographics
NPI:1023854668
Name:CONWAY COUNTY COMMUNITY SERVICE, INC
Entity type:Organization
Organization Name:CONWAY COUNTY COMMUNITY SERVICE, INC
Other - Org Name:
Other - Org Type:
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:PO BOX 679
Mailing Address - Street 2:
Mailing Address - City:MORRILTON
Mailing Address - State:AR
Mailing Address - Zip Code:72110-0679
Mailing Address - Country:US
Mailing Address - Phone:501-354-4589
Mailing Address - Fax:501-354-5410
Practice Address - Street 1:605 EUREKA AVE STE C
Practice Address - Street 2:
Practice Address - City:BERRYVILLE
Practice Address - State:AR
Practice Address - Zip Code:72616-3035
Practice Address - Country:US
Practice Address - Phone:870-929-6023
Practice Address - Fax:870-505-2003
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONWAY COUNTY COMMUNITY SERVICE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-07-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health