Healthcare Provider Details

I. General information

NPI: 1871727198
Provider Name (Legal Business Name): CONWAY COUNTY COMMUNITY SERVICE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2009
Last Update Date: 03/03/2021
Certification Date: 03/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 S OSWEGO AVE
RUSSELLVILLE AR
72802-2646
US

IV. Provider business mailing address

1415 S OSWEGO AVE
RUSSELLVILLE AR
72802-2646
US

V. Phone/Fax

Practice location:
  • Phone: 479-967-3370
  • Fax: 479-967-2775
Mailing address:
  • Phone: 479-967-3370
  • Fax: 479-967-2775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

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