Healthcare Provider Details

I. General information

NPI: 1275745044
Provider Name (Legal Business Name): VAN BUREN COUNTY AGING PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

570 YELLOWJACKET LN
CLINTON AR
72031-6769
US

IV. Provider business mailing address

570 YELLOWJACKET LN
CLINTON AR
72031-6769
US

V. Phone/Fax

Practice location:
  • Phone: 501-745-2244
  • Fax: 501-745-5204
Mailing address:
  • Phone: 501-745-2244
  • Fax: 501-745-5204

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number347C00000X
License Number StateAR

VIII. Authorized Official

Name: MR. JIMMIE LEON KIRKENDOLL
Title or Position: DIRECTOR
Credential:
Phone: 501-745-2244