1851440309 NPI number — STONERIDGE HEALTH AND REHAB CENTER

Table of content: (NPI 1851440309)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851440309 NPI number — STONERIDGE HEALTH AND REHAB CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STONERIDGE HEALTH AND REHAB CENTER
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:
STONERIDGE HEALTH & REHAB CENTER
Provider Other Organization Name Type Code:
3
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:
1851440309
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/09/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1051 LANTRIP RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHERWOOD
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72120-4161
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-833-5627
Provider Business Mailing Address Fax Number:
501-835-6905

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4017 FRANKLIN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLLEGE STATION
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72053
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-490-1533
Provider Business Practice Location Address Fax Number:
501-490-0608
Provider Enumeration Date:
01/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
LUTH
Authorized Official First Name:
KURT
Authorized Official Middle Name:
L
Authorized Official Title or Position:
REGISTERED AGENT
Authorized Official Telephone Number:
501-833-5627

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X , with the licence number:  0798 , 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: 162852311 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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