Basic Information
| Provider Information | |||||||||
| NPI: | 1518112630 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CRESTPARK WYNNE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1127 | ||||||||
| Address2: | |||||||||
| City: | WYNNE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723961127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702387941 | ||||||||
| FaxNumber: | 8702381989 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 ARKANSAS AVE E | ||||||||
| Address2: | |||||||||
| City: | WYNNE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723963407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702387941 | ||||||||
| FaxNumber: | 8702381989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2008 | ||||||||
| LastUpdateDate: | 11/18/2008 | ||||||||
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| AuthorizedOfficialLastName: | DILKS | ||||||||
| AuthorizedOfficialFirstName: | MELISHA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8708210144 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 636 | AR | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | AR | MEDICAID | 015166 | 01 | AR | BCBS PROVIDER NUMBER | OTHER |