MEDICARE: QUALIS STRATEGIC NETWORK PARTNERS, 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	:	1548823727
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	QUALIS STRATEGIC NETWORK PARTNERS, LLC

Provider Business Mailing Address
First Line	:	415 ROGERS AVE
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72901-1903
Country	:	US
Telephone Number	:	479-783-4672
Fax Number	:

Provider Business Practice Location Address
First Line	:	415 ROGERS AVE
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72901-1903
Country	:	US
Telephone Number	:	479-783-4672
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	JERRY D SAMS
Credential	:
Telephone Number	:	479-783-4672

Provider Enumeration Date	:	04/15/2019
Last Update Date	:	04/15/2019

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