Healthcare Provider Details

I. General information

NPI: 1720165434
Provider Name (Legal Business Name): PINE FOREST HEALTH AND REHAB CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 N CLIFTON ST
FORDYCE AR
71742-3026
US

IV. Provider business mailing address

203 N CLIFTON ST
FORDYCE AR
71742-3026
US

V. Phone/Fax

Practice location:
  • Phone: 870-352-3625
  • Fax: 870-352-5053
Mailing address:
  • Phone: 870-352-3625
  • Fax: 870-352-5053

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number825
License Number StateAR

VIII. Authorized Official

Name: MR. JOHN PONTHIE
Title or Position: OWNER VICE PRESIDENT
Credential:
Phone: 318-797-9066