1134521685 NPI number — WOODRIDGE OF WEST MEMPHIS, LLC

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 1134521685 NPI number — WOODRIDGE OF WEST MEMPHIS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WOODRIDGE OF WEST MEMPHIS, LLC
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:
6
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:
1134521685
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2520 NORTHWINDS PARKWAY
Provider Second Line Business Mailing Address:
SUITE 550
Provider Business Mailing Address City Name:
ALPHARETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
470-554-7903
Provider Business Mailing Address Fax Number:
615-860-9228

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 N 7TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST MEMPHIS
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72301-3235
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-394-7100
Provider Business Practice Location Address Fax Number:
870-394-7111
Provider Enumeration Date:
09/16/2014

Additional Information

Authorized Official

Authorized Official Last Name:
GERBER
Authorized Official First Name:
ROCHELLE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF ADMINISTRATIVE SERVICES
Authorized Official Telephone Number:
470-554-7903

Provider Taxonomy Codes

  • Taxonomy code: 283Q00000X , 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: 210599125 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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