Basic Information
| Provider Information | |||||||||
| NPI: | 1679057137 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HAZEN SNF OPERATOR LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MAPLE HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 S MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | HAZEN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720648306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702554323 | ||||||||
| FaxNumber: | 8702554910 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 S MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | HAZEN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720648306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702554323 | ||||||||
| FaxNumber: | 8702554910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2018 | ||||||||
| LastUpdateDate: | 01/30/2019 | ||||||||
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| AuthorizedOfficialLastName: | BROGDON | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4045494294 | ||||||||
| 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.