1114030269 NPI number — MITCHELL'S NURSING HOME, INC.

Table of content: (NPI 1114030269)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114030269 NPI number — MITCHELL'S NURSING HOME, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MITCHELL'S NURSING HOME, INC.
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:
1114030269
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DANVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72833-0010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-495-2914
Provider Business Mailing Address Fax Number:
479-495-3685

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 WEST 10TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DANVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72833
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-495-2914
Provider Business Practice Location Address Fax Number:
479-495-2914
Provider Enumeration Date:
08/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MITCHELL
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
EDWARD
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
479-495-2914

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X , with the licence number:  073 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 045454 , 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: 109435311 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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