Basic Information
| Provider Information | |||||||||
| NPI: | 1609862911 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GNC OF STAR CITY INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GARDNER NURSING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 824 SALEM RD | ||||||||
| Address2: | STE 210 | ||||||||
| City: | CONWAY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720344800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5019320050 | ||||||||
| FaxNumber: | 5018320056 | ||||||||
| Practice Location | |||||||||
| Address1: | 702 N DREW ST | ||||||||
| Address2: | |||||||||
| City: | STAR CITY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 716675728 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8706284144 | ||||||||
| FaxNumber: | 8706284891 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2005 | ||||||||
| LastUpdateDate: | 07/17/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ADAMS | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
| AuthorizedOfficialMiddleName: | BRANDON | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5019320050 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 699 | AR | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 119704311 | 05 | AR | MEDICAID |