Healthcare Provider Details

I. General information

NPI: 1023854668
Provider Name (Legal Business Name): CONWAY COUNTY COMMUNITY SERVICE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2024
Last Update Date: 07/03/2024
Certification Date: 07/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

605 EUREKA AVE STE C
BERRYVILLE AR
72616-3035
US

IV. Provider business mailing address

PO BOX 679
MORRILTON AR
72110-0679
US

V. Phone/Fax

Practice location:
  • Phone: 870-929-6023
  • Fax: 870-505-2003
Mailing address:
  • Phone: 501-354-4589
  • Fax: 501-354-5410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: ANGELA LYNN WHEAT
Title or Position: PA/CREDENTIALING CLERK
Credential:
Phone: 501-354-4589