Basic Information
Provider Information | |||||||||
NPI: | 1790730075 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BEVERLY ENTERPRISES - ARKANSAS, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | GOLDEN LIVINGCENTER - VAN BUREN | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 228 POINTER TRL W | ||||||||
Address2: |   | ||||||||
City: | VAN BUREN | ||||||||
State: | AR | ||||||||
PostalCode: | 729562266 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4794745276 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 228 POINTER TRL W | ||||||||
Address2: |   | ||||||||
City: | VAN BUREN | ||||||||
State: | AR | ||||||||
PostalCode: | 729562266 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4794745276 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/24/2006 | ||||||||
LastUpdateDate: | 08/26/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RASMUSSEN-JONES | ||||||||
AuthorizedOfficialFirstName: | HOLLY | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
AuthorizedOfficialTelephone: | 4792014835 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | BEVERLY HEALTH AND REHABILITATION SERVICES, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
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 | 109137311 | 05 | AR |   | MEDICAID |