Basic Information
| Provider Information | |||||||||
| NPI: | 1558634683 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHRIDGE HC&R NURSING LLC | ||||||||
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| OtherOrganizationName: | NORTHRIDGE HEALTHCARE AND REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2501 JOHN ASHLEY DR | ||||||||
| Address2: | |||||||||
| City: | NORTH LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721141815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5017583800 | ||||||||
| FaxNumber: | 5017582276 | ||||||||
| Practice Location | |||||||||
| Address1: | 2501 JOHN ASHLEY DR | ||||||||
| Address2: | |||||||||
| City: | NORTH LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721141815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5017583800 | ||||||||
| FaxNumber: | 5017582276 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2012 | ||||||||
| LastUpdateDate: | 05/07/2012 | ||||||||
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| AuthorizedOfficialLastName: | GENTRY | ||||||||
| AuthorizedOfficialFirstName: | BOYD | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 9379648974 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 191373311 | 05 | AR | MEDICAID |