Basic Information
| Provider Information | |||||||||
| NPI: | 1205100567 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BUFFALO RIVER THERAPY & LIVING CENTER, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 620 N PANTHER AVE | ||||||||
| Address2: | |||||||||
| City: | YELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726879313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8704494201 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 600 NORTH MAIN | ||||||||
| Address2: | SUITE A | ||||||||
| City: | MELBOURNE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703684050 | ||||||||
| FaxNumber: | 8703684054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2012 | ||||||||
| LastUpdateDate: | 03/05/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARGIS | ||||||||
| AuthorizedOfficialFirstName: | BOBBY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8703684050 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | AR | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.