Basic Information
| Provider Information | |||||||||
| NPI: | 1154541878 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST.JOHN'S PLACE OF ARKANSAS, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | ST.JOHN'S PLACE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 HIGHWAY 79 167 BYP | ||||||||
| Address2: | |||||||||
| City: | FORDYCE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 717421728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703522104 | ||||||||
| FaxNumber: | 8703528969 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 HIGHWAY 79 167 BYP | ||||||||
| Address2: | |||||||||
| City: | FORDYCE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 717421728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703522104 | ||||||||
| FaxNumber: | 8703528969 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2007 | ||||||||
| LastUpdateDate: | 07/28/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PONTHIE | ||||||||
| AuthorizedOfficialFirstName: | ROSS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3184438167 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 832 | AR | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 162887311 | 05 | AR | MEDICAID |