1134286750 NPI number — DERMOTT CITY NURSING HOME

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134286750 NPI number — DERMOTT CITY NURSING HOME

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DERMOTT CITY NURSING HOME
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134286750
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 710
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DERMOTT
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71638-0710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-538-3241
Provider Business Mailing Address Fax Number:
870-538-5763

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
702 WEST GAINES ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DERMOTT
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71638
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-538-3241
Provider Business Practice Location Address Fax Number:
870-538-5763
Provider Enumeration Date:
01/02/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ALLEN
Authorized Official First Name:
VICKI
Authorized Official Middle Name:
JEAN
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
870-538-5469

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  476 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 15172 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".