Basic Information
| Provider Information | |||||||||
| NPI: | 1245310440 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INNISFREE NURSING & REHABILITATION, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 S 24TH ST | ||||||||
| Address2: | |||||||||
| City: | ROGERS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727581116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4796365545 | ||||||||
| FaxNumber: | 4796219095 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 S 24TH ST | ||||||||
| Address2: | |||||||||
| City: | ROGERS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727581116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4796365545 | ||||||||
| FaxNumber: | 4796219095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MONTGOMERY | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4796365545 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 552 | AR | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 015302 | 01 | AR | MEDIPAK PROVIDER NUMBER | OTHER |