Healthcare Provider Details

I. General information

NPI: 1477679074
Provider Name (Legal Business Name): CREATIVE HOUSING III-NEWTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

232 N NEWTON AVE
EL DORADO AR
71730-5422
US

IV. Provider business mailing address

714 W GROVE ST
EL DORADO AR
71730-4416
US

V. Phone/Fax

Practice location:
  • Phone: 870-863-8194
  • Fax: 870-881-4600
Mailing address:
  • Phone: 870-863-8194
  • Fax: 870-881-4600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. BARBARA STAGGS
Title or Position: BUSINESS MANAGER
Credential:
Phone: 870-863-8194