MEDICARE: MALVERN OPERATIONS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1083047922
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MALVERN OPERATIONS, LLC

Provider Business Mailing Address
First Line	:	105 RUSSELLVILLE RD
Second Line	:
City	:	MALVERN
State	:	AR
Zip	:	72104-6700
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	105 RUSSELLVILLE RD
Second Line	:
City	:	MALVERN
State	:	AR
Zip	:	72104-6700
Country	:	US
Telephone Number	:	501-332-5251
Fax Number	:

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	MR. ROSS PONTHIE
Credential	:
Telephone Number	:	318-443-8167

Provider Enumeration Date	:	08/14/2013
Last Update Date	:	04/15/2015

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Directions to “MALVERN OPERATIONS, LLC ” Practice Location

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