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General NPI Number Information
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NPI Number | 1043583412
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Entity Type | Organization
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Legal Business Name | SOURCES FOR COMMUNITY INDEPENDENT LIVING SERVICES, INC.
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Dates
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Enumeration Date | 02/16/2012
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Last Update Date | 02/16/2012
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Provider Practice Location Address
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Address Line | 1918 N BIRCH AVE
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City | FAYETTEVILLE
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State | AR
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Zip | 72703-2408
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Country | US
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Telephone | 479-442-5600
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Fax |
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Provider Business Mailing Address
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Address Line | 1918 N BIRCH AVE
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City | FAYETTEVILLE
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State | AR
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Zip | 72703-2408
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | JIM MATHER
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Credential |
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Telephone | 479-442-5600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number | CS014
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License Number State | AR
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