Basic Information
| Provider Information | |||||||||
| NPI: | 1417978305 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | REHOBOTH, INCORPORATED | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE HOME PLACE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 900 W 12TH ST | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728016606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4799685858 | ||||||||
| FaxNumber: | 4798906013 | ||||||||
| Practice Location | |||||||||
| Address1: | 2004 N 2ND ST | ||||||||
| Address2: | |||||||||
| City: | DARDANELLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728342601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4799685858 | ||||||||
| FaxNumber: | 4798906013 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | BRASHEAR | ||||||||
| AuthorizedOfficialFirstName: | REBECCA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4799685858 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320700000X | 353 | AR | Y | Residential Treatment Facilities | Residential Treatment Facility, Physical Disabilities |
No ID Information.