Basic Information
| Provider Information | |||||||||
| NPI: | 1831433598 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BNNC INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | ALCOA PINES HEALTH AND REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 ALCOA RD | ||||||||
| Address2: | |||||||||
| City: | BENTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720156032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013151700 | ||||||||
| FaxNumber: | 5013151720 | ||||||||
| Practice Location | |||||||||
| Address1: | 3300 ALCOA RD | ||||||||
| Address2: | |||||||||
| City: | BENTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720156032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013151700 | ||||||||
| FaxNumber: | 5013151720 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2012 | ||||||||
| LastUpdateDate: | 02/15/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ADAMS | ||||||||
| AuthorizedOfficialFirstName: | ANTHONY | ||||||||
| AuthorizedOfficialMiddleName: | BRANDON | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5019320050 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OVATION HEALTH SYSTEMS INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 994 | AR | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 195058311 | 05 | AR | MEDICAID |