Basic Information
| Provider Information | |||||||||
| NPI: | 1285059261 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SLNC, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SOUTHFORK RIVER THERAPY AND LIVING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 624 HWY 62/412 WEST | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | AR | ||||||||
| PostalCode: | 725769829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708953817 | ||||||||
| FaxNumber: | 8708953009 | ||||||||
| Practice Location | |||||||||
| Address1: | 624 HWY 62/412 WEST | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | AR | ||||||||
| PostalCode: | 725769829 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708953817 | ||||||||
| FaxNumber: | 8708953009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2014 | ||||||||
| LastUpdateDate: | 11/11/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ADAMS | ||||||||
| AuthorizedOfficialFirstName: | BRANDON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8708953817 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | EAGLE HEALTH SYSTEMS, INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 1050 | AR | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 202093311 | 05 | AR | MEDICAID |