Basic Information
| Provider Information | |||||||||
| NPI: | 1780906867 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHRISTIAN HEALTH CARE OF SPRINGFIELD WEST PARK, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | BROOKHAVEN HEALTH CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 222 S 1ST ST | ||||||||
| Address2: | |||||||||
| City: | ROGERS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727564504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794640200 | ||||||||
| FaxNumber: | 4794648098 | ||||||||
| Practice Location | |||||||||
| Address1: | 3405 W MOUNT VERNON ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658025241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178749600 | ||||||||
| FaxNumber: | 4178749601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2010 | ||||||||
| LastUpdateDate: | 11/28/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | STAYTON | ||||||||
| AuthorizedOfficialFirstName: | PHYLLIS | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CLINICAL SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 4173435401 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | R.N. | ||||||||
| NPICertificationDate: | |||||||||
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 | 101451110 | 05 | MO | MEDICAID |