Basic Information
Provider Information | |||||||||
NPI: | 1326113689 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ST. JOHN'S PLACE OF ARKANSAS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1025 | ||||||||
Address2: |   | ||||||||
City: | FORDYCE | ||||||||
State: | AR | ||||||||
PostalCode: | 717421025 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8703522104 | ||||||||
FaxNumber: | 8703528969 | ||||||||
Practice Location | |||||||||
Address1: | 815 BAXTER ST. | ||||||||
Address2: |   | ||||||||
City: | FORDYCE | ||||||||
State: | AR | ||||||||
PostalCode: | 717421025 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8703522104 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/22/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PONTHIE | ||||||||
AuthorizedOfficialFirstName: | ROSS | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
AuthorizedOfficialTelephone: | 3184438167 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X |   |   | Y |   | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |   |
No ID Information.