Basic Information
| Provider Information | |||||||||
| NPI: | 1194897355 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CONCORDIA QUILT, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CONCORDIA CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 7 PROFESSIONAL DR | ||||||||
| Address2: | |||||||||
| City: | BELLA VISTA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727142462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4798553735 | ||||||||
| FaxNumber: | 4798554697 | ||||||||
| Practice Location | |||||||||
| Address1: | 7 PROFESSIONAL DR | ||||||||
| Address2: | |||||||||
| City: | BELLA VISTA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727142462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4798553735 | ||||||||
| FaxNumber: | 4798554697 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WITT | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 5057978735 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 376 | AR | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | V564P-1054 | 01 | AR | VA PROVIDER NUMBER | OTHER |