Healthcare Provider Details

I. General information

NPI: 1134286750
Provider Name (Legal Business Name): DERMOTT CITY NURSING HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 WEST GAINES ST.
DERMOTT AR
71638
US

IV. Provider business mailing address

PO BOX 710
DERMOTT AR
71638-0710
US

V. Phone/Fax

Practice location:
  • Phone: 870-538-3241
  • Fax: 870-538-5763
Mailing address:
  • Phone: 870-538-3241
  • Fax: 870-538-5763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number476
License Number StateAR

VIII. Authorized Official

Name: MS. VICKI JEAN ALLEN
Title or Position: ADMINISTRATOR
Credential:
Phone: 870-538-5469