Healthcare Provider Details

I. General information

NPI: 1457063968
Provider Name (Legal Business Name): SOUTHERN CAREGIVERS OF CONWAY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2022
Last Update Date: 12/15/2022
Certification Date: 12/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 DEER ST STE 5
CONWAY AR
72032-5450
US

IV. Provider business mailing address

PO BOX 399
MAGNOLIA AR
71754-0399
US

V. Phone/Fax

Practice location:
  • Phone: 501-463-9990
  • Fax: 501-406-8815
Mailing address:
  • Phone: 501-463-9990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER HOOPER
Title or Position: QUALITY DIRECTOR
Credential:
Phone: 501-701-9122