Provider Demographics
NPI:1639159973
Name:CROSSETT HEALTH FOUNDATION
Entity type:Organization
Organization Name:CROSSETT HEALTH FOUNDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GLYNDA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:SAPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-364-9111
Mailing Address - Street 1:PO BOX 340
Mailing Address - Street 2:
Mailing Address - City:CROSSETT
Mailing Address - State:AR
Mailing Address - Zip Code:71635-0340
Mailing Address - Country:US
Mailing Address - Phone:870-364-9111
Mailing Address - Fax:
Practice Address - Street 1:909 UNITY RD
Practice Address - Street 2:
Practice Address - City:CROSSETT
Practice Address - State:AR
Practice Address - Zip Code:71635-9444
Practice Address - Country:US
Practice Address - Phone:870-364-9111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CROSSETT HEALTH FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-20
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC-1417261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR222944002Medicaid
AR121497002Medicaid