Healthcare Provider Details

I. General information

NPI: 1326113689
Provider Name (Legal Business Name): ST. JOHN'S PLACE OF ARKANSAS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 BAXTER ST.
FORDYCE AR
71742-1025
US

IV. Provider business mailing address

PO BOX 1025
FORDYCE AR
71742-1025
US

V. Phone/Fax

Practice location:
  • Phone: 870-352-2104
  • Fax:
Mailing address:
  • Phone: 870-352-2104
  • Fax: 870-352-8969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

Name: ROSS PONTHIE
Title or Position: MANAGING MEMBER
Credential:
Phone: 318-443-8167