1851405468 NPI number — RIVENDELL BEHAVIORAL HEALTH SERVICES OF AR

Table of content: (NPI 1851405468)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851405468 NPI number — RIVENDELL BEHAVIORAL HEALTH SERVICES OF AR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RIVENDELL BEHAVIORAL HEALTH SERVICES OF AR
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:
1851405468
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:
100 RIVENDELL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BENTON
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72015-9188
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-316-1255
Provider Business Mailing Address Fax Number:
501-794-0908

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1405 N PIERCE ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72207-5349
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-603-2147
Provider Business Practice Location Address Fax Number:
501-603-0324
Provider Enumeration Date:
08/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LEWIS
Authorized Official First Name:
LISA
Authorized Official Middle Name:
ELIZABETH
Authorized Official Title or Position:
THERAPIST
Authorized Official Telephone Number:
501-603-2147

Provider Taxonomy Codes

  • Taxonomy code: 261QM0801X , with the licence number:  1382-C , 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)





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