Basic Information
Provider Information | |||||||||
NPI: | 1932235025 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | VICTORIA EUREKA SPRINGS INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BRIGHTON RIDGE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2010 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | VAN BUREN | ||||||||
State: | AR | ||||||||
PostalCode: | 729564957 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4794746885 | ||||||||
FaxNumber: | 4794749523 | ||||||||
Practice Location | |||||||||
Address1: | 235 HUNTSVILLE RD | ||||||||
Address2: |   | ||||||||
City: | EUREKA SPRINGS | ||||||||
State: | AR | ||||||||
PostalCode: | 726329572 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4792537038 | ||||||||
FaxNumber: | 4792532954 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/26/2007 | ||||||||
LastUpdateDate: | 01/12/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KILGORE | ||||||||
AuthorizedOfficialFirstName: | JENNY | ||||||||
AuthorizedOfficialMiddleName: | JUNE | ||||||||
AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
AuthorizedOfficialTelephone: | 4794746885 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CPA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 835 | AR | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 163457311 | 05 | AR |   | MEDICAID | 15242 | 01 | AR | OTHER INSURANCE | OTHER |