Basic Information
| Provider Information | |||||||||
| NPI: | 1699765958 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROSE & WELLS, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LEGACY LODGE NURSING HOME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 900 W 12TH ST | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728016606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4799685858 | ||||||||
| FaxNumber: | 4798906013 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 W 12TH ST | ||||||||
| Address2: | |||||||||
| City: | RUSSELLVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728016606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4799685858 | ||||||||
| FaxNumber: | 4798906013 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2005 | ||||||||
| LastUpdateDate: | 11/29/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRASHEAR | ||||||||
| AuthorizedOfficialFirstName: | REBECCA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4799685858 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | R.N. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 037 | AR | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
No ID Information.