Basic Information
Provider Information | |||||||||
NPI: | 1043206360 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HERITAGE SQUARE NURSING AND REHABILITATION CENTER, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 710 N RUDDLE RD | ||||||||
Address2: |   | ||||||||
City: | BLYTHEVILLE | ||||||||
State: | AR | ||||||||
PostalCode: | 723152137 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8707633654 | ||||||||
FaxNumber: | 8707621172 | ||||||||
Practice Location | |||||||||
Address1: | 710 N RUDDLE RD | ||||||||
Address2: |   | ||||||||
City: | BLYTHEVILLE | ||||||||
State: | AR | ||||||||
PostalCode: | 723152137 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8707633654 | ||||||||
FaxNumber: | 8707621172 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/22/2005 | ||||||||
LastUpdateDate: | 06/30/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ADAMS | ||||||||
AuthorizedOfficialFirstName: | A | ||||||||
AuthorizedOfficialMiddleName: | BRANDON | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 5019320050 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 672 | AR | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 119680311 | 05 | AR |   | MEDICAID |