Basic Information
| Provider Information | |||||||||
| NPI: | 1760458814 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BANYAN HEALTHCARE SERVICES, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | DIERKS HEALTH & REHAB CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1051 LANTRIP RD | ||||||||
| Address2: | |||||||||
| City: | SHERWOOD | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721204161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5018335627 | ||||||||
| FaxNumber: | 5018356905 | ||||||||
| Practice Location | |||||||||
| Address1: | 402 S. ARKANSAS AVE | ||||||||
| Address2: | |||||||||
| City: | DIERKS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 71833 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702863100 | ||||||||
| FaxNumber: | 8702863030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2006 | ||||||||
| LastUpdateDate: | 12/09/2014 | ||||||||
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| AuthorizedOfficialLastName: | LUTH | ||||||||
| AuthorizedOfficialFirstName: | KURT | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | REGISTERED AGENT | ||||||||
| AuthorizedOfficialTelephone: | 5018335627 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 769 | AR | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 155080311 | 05 | AR | MEDICAID |