Basic Information
| Provider Information | |||||||||
| NPI: | 1649269259 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CCNRC, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CARROLL COUNTY NURSING AND REHAB CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 918 | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 725560918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8704236966 | ||||||||
| FaxNumber: | 8704236105 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 HAMMONDS AVE | ||||||||
| Address2: | |||||||||
| City: | BERRYVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 726164300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8704236966 | ||||||||
| FaxNumber: | 8703684054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | NELSON | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8704236966 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 758 | AR | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.