Healthcare Provider Details

I. General information

NPI: 1760458814
Provider Name (Legal Business Name): BANYAN HEALTHCARE SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 12/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 S. ARKANSAS AVE
DIERKS AR
71833
US

IV. Provider business mailing address

1051 LANTRIP RD
SHERWOOD AR
72120-4161
US

V. Phone/Fax

Practice location:
  • Phone: 870-286-3100
  • Fax: 870-286-3030
Mailing address:
  • Phone: 501-833-5627
  • Fax: 501-835-6905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number769
License Number StateAR

VIII. Authorized Official

Name: MR. KURT LEE LUTH
Title or Position: REGISTERED AGENT
Credential:
Phone: 501-833-5627