Basic Information
| Provider Information | |||||||||
| NPI: | 1477646552 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHRISTIAN HEALTH CARE OF LEBANON NORTH, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 222 S 1ST ST | ||||||||
| Address2: | |||||||||
| City: | ROGERS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727564504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794640200 | ||||||||
| FaxNumber: | 4794648098 | ||||||||
| Practice Location | |||||||||
| Address1: | 596 MORTON RD | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 655363648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4175329173 | ||||||||
| FaxNumber: | 4175328223 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 12/20/2011 | ||||||||
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| AuthorizedOfficialLastName: | STAYTON | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4178919939 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 032279 | MO | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 101489409 | 05 | MO | MEDICAID |