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General NPI Number Information
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NPI Number | 1508917295
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Entity Type | Organization
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Legal Business Name | CIVITAN CENTER
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Dates
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Enumeration Date | 01/16/2007
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Last Update Date | 03/10/2014
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Provider Practice Location Address
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Address Line | 121 SOUTH COX STREET 121 SOUTH COX STREET
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City | BENTON
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State | AR
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Zip | 72018-0368
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Country | US
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Telephone | 501-776-0691
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Fax | 501-776-0692
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Provider Business Mailing Address
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Address Line | 121 SOUTH COX STREET P. O. BOX 368
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City | BENTON
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State | AR
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Zip | 72018-0368
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Country | US
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Telephone | 501-776-0691
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Fax | 501-776-0692
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MRS. LEAH L. HENDERSON
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Credential | MSE-ECSE
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Telephone | 501-776-0691
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number |
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License Number State | AR
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