Basic Information
| Provider Information | |||||||||
| NPI: | 1922582477 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WATERS OF FORT SMITH LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5301 WHEELER AVE | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729018339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4796463454 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5301 WHEELER AVE | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729018339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4796463454 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2018 | ||||||||
| LastUpdateDate: | 08/05/2020 | ||||||||
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| AuthorizedOfficialLastName: | GUBIN | ||||||||
| AuthorizedOfficialFirstName: | MOISHE | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7084491900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.