1164748463 NPI number — BENTONVILLE ASSISTED LIVING SERVICES

Table of content: (NPI 1164748463)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164748463 NPI number — BENTONVILLE ASSISTED LIVING SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BENTONVILLE ASSISTED LIVING SERVICES
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:
1164748463
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
808 N MAIN ST APT 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BENTONVILLE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72712-4830
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-273-7344
Provider Business Mailing Address Fax Number:
479-464-7169

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3317 SE L ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BENTONVILLE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72712-3793
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-254-8759
Provider Business Practice Location Address Fax Number:
479-254-9349
Provider Enumeration Date:
04/12/2010

Additional Information

Authorized Official

Authorized Official Last Name:
OPPENHEIM
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
479-426-6510

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  180230794 , 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: 180230794 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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