Basic Information
Provider Information | |||||||||
NPI: | 1154805570 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WEST DIXON ASSISTED LIVING - A WATERS COMMUNITY, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2821 W DIXON RD | ||||||||
Address2: |   | ||||||||
City: | LITTLE ROCK | ||||||||
State: | AR | ||||||||
PostalCode: | 722064256 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5018884080 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2821 W DIXON RD | ||||||||
Address2: |   | ||||||||
City: | LITTLE ROCK | ||||||||
State: | AR | ||||||||
PostalCode: | 722064256 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5018884080 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/21/2018 | ||||||||
LastUpdateDate: | 09/21/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BLISKO | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MBR | ||||||||
AuthorizedOfficialTelephone: | 7084491900 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X |   |   | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.