Healthcare Provider Details

I. General information

NPI: 1962637082
Provider Name (Legal Business Name): CONWAY COUNTY COMMUNITY SERVICE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2009
Last Update Date: 03/03/2021
Certification Date: 03/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 SHAKE RAG RD
CLINTON AR
72031-6682
US

IV. Provider business mailing address

P.O. BOX 1133
CLINTON AR
72031
US

V. Phone/Fax

Practice location:
  • Phone: 501-745-2956
  • Fax: 501-745-6918
Mailing address:
  • Phone: 501-745-2956
  • Fax: 501-745-2956

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