Basic Information
| Provider Information | |||||||||
| NPI: | 1760413959 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEMORIAL HEALTH & REHAB, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEMORIAL NURSING CENTER OF BLYTHEVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 824 SALEM RD | ||||||||
| Address2: | STE. 210 | ||||||||
| City: | CONWAY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720344821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5019320050 | ||||||||
| FaxNumber: | 5019320056 | ||||||||
| Practice Location | |||||||||
| Address1: | 824 SALEM RD | ||||||||
| Address2: | STE. 210 | ||||||||
| City: | CONWAY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720344821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5019320050 | ||||||||
| FaxNumber: | 5019320056 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 12/06/2007 | ||||||||
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| AuthorizedOfficialLastName: | ADAMS | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
| AuthorizedOfficialMiddleName: | BRANDON | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5019320050 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 722 | AR | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.