Basic Information
| Provider Information | |||||||||
| NPI: | 1033424833 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CLARKSVILLE COMMUNITY HEALTH & REHABILITATION LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9785 CROSSPOINT BLVD STE 104 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462563321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175989467 | ||||||||
| FaxNumber: | 3178450616 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 OAK CT | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728303778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178412377 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2010 | ||||||||
| LastUpdateDate: | 04/20/2011 | ||||||||
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| AuthorizedOfficialLastName: | KEMPER | ||||||||
| AuthorizedOfficialFirstName: | JERRY | ||||||||
| AuthorizedOfficialMiddleName: | V. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3175989586 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 314000000X | 945 | AR | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 186044311 | 05 | AR | MEDICAID |