Healthcare Provider Details

I. General information

NPI: 1508917295
Provider Name (Legal Business Name): CIVITAN CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 03/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 SOUTH COX STREET 121 SOUTH COX STREET
BENTON AR
72018-0368
US

IV. Provider business mailing address

121 SOUTH COX STREET P. O. BOX 368
BENTON AR
72018-0368
US

V. Phone/Fax

Practice location:
  • Phone: 501-776-0691
  • Fax: 501-776-0692
Mailing address:
  • Phone: 501-776-0691
  • Fax: 501-776-0692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateAR

VIII. Authorized Official

Name: MRS. LEAH L. HENDERSON
Title or Position: EXECUTIVE DIRECTOR
Credential: MSE-ECSE
Phone: 501-776-0691