Basic Information
| Provider Information | |||||||||
| NPI: | 1649595620 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OSCEOLA HEALTHCARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 287 SO. COUNTRY CLUB ROAD | ||||||||
| Address2: | |||||||||
| City: | OSCEOLA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723706047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705633201 | ||||||||
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| Practice Location | |||||||||
| Address1: | 287 S COUNTRY CLUB RD | ||||||||
| Address2: | |||||||||
| City: | OSCEOLA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723706047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8705633201 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2010 | ||||||||
| LastUpdateDate: | 04/01/2010 | ||||||||
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| AuthorizedOfficialLastName: | THREKELD | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADM. | ||||||||
| AuthorizedOfficialTelephone: | 8705633201 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 544 | AR | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 180796311 | 05 | AR | MEDICAID |