Healthcare Provider Details

I. General information

NPI: 1326120502
Provider Name (Legal Business Name): RUSSELLVILLE HEALTH CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 08/26/2022
Certification Date: 08/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 GANDY ST NE
RUSSELLVILLE AL
35653-1913
US

IV. Provider business mailing address

705 GANDY ST NE
RUSSELLVILLE AL
35653-1913
US

V. Phone/Fax

Practice location:
  • Phone: 256-332-3773
  • Fax: 256-332-1292
Mailing address:
  • Phone: 256-332-3773
  • Fax: 256-332-1292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number12541
License Number StateAL

VIII. Authorized Official

Name: MRS. BRENDA GAIL HOVATER
Title or Position: NURSING HOME ADMINISTRATOR
Credential:
Phone: 256-332-3773