Basic Information
| Provider Information | |||||||||
| NPI: | 1386810604 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UHS OF BENTON, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | RIVENDELL BEHAVIORAL HEALTH SERVICES OF AR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 278 S FLORIDA ST | ||||||||
| Address2: | |||||||||
| City: | MARIANNA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723602741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013161255 | ||||||||
| FaxNumber: | 5017940908 | ||||||||
| Practice Location | |||||||||
| Address1: | 278 S FLORIDA ST | ||||||||
| Address2: | |||||||||
| City: | MARIANNA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723602741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013161255 | ||||||||
| FaxNumber: | 5017940908 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2008 | ||||||||
| LastUpdateDate: | 05/06/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILLIAMS | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5013161255 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0850X | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM0855X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 167272526 | 05 | AR | MEDICAID |