Healthcare Provider Details

I. General information

NPI: 1770537565
Provider Name (Legal Business Name): CRYSTAL FALLS HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 03/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1206 W COLLIN RAYE DR
DE QUEEN AR
71832-2030
US

IV. Provider business mailing address

1206 W COLLIN RAYE DR
DE QUEEN AR
71832-2030
US

V. Phone/Fax

Practice location:
  • Phone: 870-642-3317
  • Fax: 870-642-6667
Mailing address:
  • Phone: 870-642-3317
  • Fax: 870-642-6667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number796
License Number StateAR

VIII. Authorized Official

Name: MRS. DEBBIE J PERRON
Title or Position: REGIONAL BUSINESS OFFICE MANAGER
Credential:
Phone: 501-888-4200