1174781645 NPI number — SUPERIOR SENIOR CARE

Table of content: (NPI 1174781645)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174781645 NPI number — SUPERIOR SENIOR CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUPERIOR SENIOR CARE
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:
1174781645
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 505
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOT SPRINGS
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
71902-0505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-321-1743
Provider Business Mailing Address Fax Number:
501-623-7853

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
835 CENTRAL AVE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
HOT SPRINGS
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
71901-5318
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-321-1743
Provider Business Practice Location Address Fax Number:
501-623-7853
Provider Enumeration Date:
05/30/2008

Additional Information

Authorized Official

Authorized Official Last Name:
TRAWICK
Authorized Official First Name:
TRACY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CORPORATE OFFICE MANAGER
Authorized Official Telephone Number:
501-321-1743

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X , with the licence number:  141026765 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 253Z00000X , with the licence number: 141025732 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 123989757 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 164215797 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 126107752 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 164300796 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 164592798 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 126106750 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 141025732 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 141026765 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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