Basic Information
| Provider Information | |||||||||
| NPI: | 1174903025 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SRN MANAGEMENT, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COTTAGE LANE HEALTH AND REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8520 S 36TH TER | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729088880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794101740 | ||||||||
| FaxNumber: | 4794101596 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 BROOKSIDE DR | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722051644 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5012243940 | ||||||||
| FaxNumber: | 5012246649 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2015 | ||||||||
| LastUpdateDate: | 10/18/2016 | ||||||||
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| AuthorizedOfficialLastName: | RYE | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | ANDREW | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4794101740 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1059 | AR | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 208289311 | 05 | AR | MEDICAID |