Healthcare Provider Details

I. General information

NPI: 1962113399
Provider Name (Legal Business Name): THE SHAVERS-COBB FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2022
Last Update Date: 12/06/2022
Certification Date: 12/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2307 FOREST KNOLL DR
PINE BLUFF AR
71603-6154
US

IV. Provider business mailing address

2307 FOREST KNOLL DR
PINE BLUFF AR
71603-6154
US

V. Phone/Fax

Practice location:
  • Phone: 870-556-0335
  • Fax:
Mailing address:
  • Phone: 870-556-0335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QP0905X
TaxonomyState or Local Public Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DONOVAN L SHAVERS
Title or Position: EXECUTIVE DIRECTOR/FOUNDER
Credential: MPH
Phone: 870-556-0335