Basic Information
| Provider Information | |||||||||
| NPI: | 1295914802 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WONDER BOYS PROPERTIES OF ARKANSAS, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | VAN BUREN HEALTHCARE AND REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8520 S 36TH TER | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729088880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794101740 | ||||||||
| FaxNumber: | 4794101596 | ||||||||
| Practice Location | |||||||||
| Address1: | 1404 N 28TH ST | ||||||||
| Address2: | |||||||||
| City: | VAN BUREN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729562931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794748022 | ||||||||
| FaxNumber: | 4794718570 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2007 | ||||||||
| LastUpdateDate: | 10/11/2013 | ||||||||
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| AuthorizedOfficialLastName: | RYE | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | ANDREW | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4794101740 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 845 | AR | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 165666311 | 05 | AR | MEDICAID |