Healthcare Provider Details

I. General information

NPI: 1558588764
Provider Name (Legal Business Name): CRAWFORD-SEBASTIAN COMMUNITY DEVELOPMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 10/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 NO. 17TH
FORT SMITH AR
72901
US

IV. Provider business mailing address

PO BOX 4069
FORT SMITH AR
72914-4069
US

V. Phone/Fax

Practice location:
  • Phone: 479-782-6021
  • Fax: 479-709-0161
Mailing address:
  • Phone: 479-785-2303
  • Fax: 479-785-2341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number101872002
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number StateAR

VIII. Authorized Official

Name: MR. MARK WHITMER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 479-785-2303