Basic Information
| Provider Information | |||||||||
| NPI: | 1679890511 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STAP, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ST. ANDREWS PLACE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2010 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | VAN BUREN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729564957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794746885 | ||||||||
| FaxNumber: | 4794749523 | ||||||||
| Practice Location | |||||||||
| Address1: | 3501 COLLEGE AVE | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720347281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013299879 | ||||||||
| FaxNumber: | 5013296673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2010 | ||||||||
| LastUpdateDate: | 06/10/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KILGORE | ||||||||
| AuthorizedOfficialFirstName: | JENNY | ||||||||
| AuthorizedOfficialMiddleName: | JUNE | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4794746885 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | AR | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 181708311 | 05 | AR | MEDICAID |