Basic Information
| Provider Information | |||||||||
| NPI: | 1205267101 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MENA HEALTH, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MENA MANOR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 222 S 1ST ST | ||||||||
| Address2: | |||||||||
| City: | ROGERS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727564509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794640200 | ||||||||
| FaxNumber: | 4794648098 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 9TH ST | ||||||||
| Address2: | |||||||||
| City: | MENA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719533026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4793942617 | ||||||||
| FaxNumber: | 4793943928 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2013 | ||||||||
| LastUpdateDate: | 11/06/2014 | ||||||||
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| AuthorizedOfficialLastName: | LONG | ||||||||
| AuthorizedOfficialFirstName: | PHILLIP | ||||||||
| AuthorizedOfficialMiddleName: | CODY | ||||||||
| AuthorizedOfficialTitleorPosition: | TREASURER & CFO | ||||||||
| AuthorizedOfficialTelephone: | 4794640200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 201135311 | 05 | AR | MEDICAID |