Basic Information
Provider Information | |||||||||
NPI: | 1801179973 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | STONEYBROOK HEALTHCARE & REHAB, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | STONEYBROOK HEALTH AND REHABILITATION CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4704 HIXSON PIKE | ||||||||
Address2: |   | ||||||||
City: | HIXSON | ||||||||
State: | TN | ||||||||
PostalCode: | 373434840 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4238772024 | ||||||||
FaxNumber: | 4238772328 | ||||||||
Practice Location | |||||||||
Address1: | 3300 MILITARY RD | ||||||||
Address2: |   | ||||||||
City: | BENTON | ||||||||
State: | AR | ||||||||
PostalCode: | 720152581 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4238772024 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/24/2011 | ||||||||
LastUpdateDate: | 07/09/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JONES | ||||||||
AuthorizedOfficialFirstName: | DEBORAH | ||||||||
AuthorizedOfficialMiddleName: | JEAN | ||||||||
AuthorizedOfficialTitleorPosition: | COO | ||||||||
AuthorizedOfficialTelephone: | 4238772024 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X |   |   | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.