Basic Information
| Provider Information | |||||||||
| NPI: | 1164436317 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CRITTENDEN CARES, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PROCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3026 | ||||||||
| Address2: | |||||||||
| City: | WEST MEMPHIS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723033026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707323353 | ||||||||
| FaxNumber: | 8707322662 | ||||||||
| Practice Location | |||||||||
| Address1: | 308 S RHODES ST | ||||||||
| Address2: | |||||||||
| City: | WEST MEMPHIS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723014215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8707323353 | ||||||||
| FaxNumber: | 8707322662 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 12/18/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CASHMAN | ||||||||
| AuthorizedOfficialFirstName: | EUGENE | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8707351500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CRITTENDEN CARES, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | AR4269 | AR | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 10530 | 01 | AR | BLUE CROSS BLUE SHIELD | OTHER |