Basic Information
| Provider Information | |||||||||
| NPI: | 1689973273 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COUNTRY CLUB GARDENS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 ROGERS AVE | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729011903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797834672 | ||||||||
| FaxNumber: | 4797832217 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 PITTMAN RD | ||||||||
| Address2: | |||||||||
| City: | HOT SPRINGS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 719139001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5017677530 | ||||||||
| FaxNumber: | 5017677534 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2011 | ||||||||
| LastUpdateDate: | 04/17/2020 | ||||||||
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| AuthorizedOfficialLastName: | MORTON | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 4797834672 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 04/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 187641311 | 05 | AR | MEDICAID |