Healthcare Provider Details

I. General information

NPI: 1962622506
Provider Name (Legal Business Name): ST JOHN'S PLACE OF ARKANSAS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2007
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: LINDA G. SCALES
Title or Position: ADMINISTRATOR
Credential:
Phone: 870-352-3625