Basic Information
| Provider Information | |||||||||
| NPI: | 1659526762 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CRESTPARK MARIANNA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 386 | ||||||||
| Address2: | |||||||||
| City: | MARIANNA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723600386 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702953466 | ||||||||
| FaxNumber: | 8702955474 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 W CHESTNUT ST | ||||||||
| Address2: | |||||||||
| City: | MARIANNA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 723602160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702953466 | ||||||||
| FaxNumber: | 8702955474 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2008 | ||||||||
| LastUpdateDate: | 05/15/2015 | ||||||||
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| AuthorizedOfficialLastName: | BELEW | ||||||||
| AuthorizedOfficialFirstName: | BARBARA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5016267986 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 634 | AR | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 045449 | 01 | AR | MEDICARE TPIN | OTHER | 178269311 | 05 | AR | MEDICAID |