Basic Information
Provider Information | |||||||||
NPI: | 1255327508 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | INNISFREE NURSING CTR INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 301 S 24TH ST | ||||||||
Address2: |   | ||||||||
City: | ROGERS | ||||||||
State: | AR | ||||||||
PostalCode: | 727581116 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4796365545 | ||||||||
FaxNumber: | 4796369095 | ||||||||
Practice Location | |||||||||
Address1: | 301 S 24TH ST | ||||||||
Address2: |   | ||||||||
City: | ROGERS | ||||||||
State: | AR | ||||||||
PostalCode: | 727581116 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4796365545 | ||||||||
FaxNumber: | 4796369095 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/22/2005 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RUSGIS | ||||||||
AuthorizedOfficialFirstName: | CHARLES | ||||||||
AuthorizedOfficialMiddleName: | JOHN | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 4796365545 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: | JR. | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | 552 | AR | Y |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   |
ID Information
ID | Type | State | Issuer | Description | 15302 | 01 | AR | BCBS | OTHER |