Basic Information
Provider Information | |||||||||
NPI: | 1376531202 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FCNRC, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SOUTHFORK RIVER THERAPY & LIVING CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 918 | ||||||||
Address2: |   | ||||||||
City: | MELBOURNE | ||||||||
State: | AR | ||||||||
PostalCode: | 725560918 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8708953817 | ||||||||
FaxNumber: | 8703684054 | ||||||||
Practice Location | |||||||||
Address1: | 624 HWY 62/412 WEST | ||||||||
Address2: |   | ||||||||
City: | SALEM | ||||||||
State: | AR | ||||||||
PostalCode: | 72576 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8708953817 | ||||||||
FaxNumber: | 8703684054 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/13/2005 | ||||||||
LastUpdateDate: | 09/25/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TAYLOR | ||||||||
AuthorizedOfficialFirstName: | JOHNIECE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SEC | ||||||||
AuthorizedOfficialTelephone: | 8703684054 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 760 | AR | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 154017311 | 05 | AR |   | MEDICAID |