Healthcare Provider Details

I. General information

NPI: 1770631467
Provider Name (Legal Business Name): CONWAY COUNTY COMMUNITY SERVICE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 03/03/2021
Certification Date: 03/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 S CHEROKEE ST.
MORRILTON AR
72110
US

IV. Provider business mailing address

PO BOX 679
MORRILTON AR
72110
US

V. Phone/Fax

Practice location:
  • Phone: 501-354-4589
  • Fax: 501-354-5410
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 Number10085
License Number StateAR

VIII. Authorized Official

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