Basic Information
| Provider Information | |||||||||
| NPI: | 1912227109 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOMETOWN | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 512 SE MILLER | ||||||||
| Address2: | |||||||||
| City: | HOXIE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708091695 | ||||||||
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| Practice Location | |||||||||
| Address1: | 503 LINDSEY | ||||||||
| Address2: | |||||||||
| City: | HOXIE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8708861333 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2010 | ||||||||
| LastUpdateDate: | 06/10/2010 | ||||||||
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| AuthorizedOfficialLastName: | TINKER | ||||||||
| AuthorizedOfficialFirstName: | LANNY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8708861333 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
No ID Information.