Provider Demographics
NPI:1255339990
Name:CROSSETT HEALTH FOUNDATION
Entity type:Organization
Organization Name:CROSSETT HEALTH FOUNDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:LEANN
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:870-364-5555
Mailing Address - Street 1:PO BOX 400
Mailing Address - Street 2:
Mailing Address - City:CROSSETT
Mailing Address - State:AR
Mailing Address - Zip Code:71635-0400
Mailing Address - Country:US
Mailing Address - Phone:870-364-5555
Mailing Address - Fax:870-364-5577
Practice Address - Street 1:211 PINE ST
Practice Address - Street 2:
Practice Address - City:CROSSETT
Practice Address - State:AR
Practice Address - Zip Code:71635
Practice Address - Country:US
Practice Address - Phone:870-364-5555
Practice Address - Fax:870-364-5577
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ASHLEY COUNTY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-07-07
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR4428251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR116070514Medicaid
AR116070514Medicaid