Basic Information
| Provider Information | |||||||||
| NPI: | 1639652506 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LTC OF CONWAY, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST. ANDREWS HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3750 OSAGE BEACH PKWY | ||||||||
| Address2: | |||||||||
| City: | OSAGE BEACH | ||||||||
| State: | MO | ||||||||
| PostalCode: | 650652179 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3501 COLLEGE AVE | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720347281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013299879 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2018 | ||||||||
| LastUpdateDate: | 09/07/2018 | ||||||||
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| AuthorizedOfficialLastName: | DASAL | ||||||||
| AuthorizedOfficialFirstName: | MATHIAS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5737467100 | ||||||||
| IsSoleProprietor: | |||||||||
| 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 |
No ID Information.