Healthcare Provider Details

I. General information

NPI: 1902869787
Provider Name (Legal Business Name): FOUNTAIN LAKE HEALTH AND REHAB INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 WOODFIN ST
HOT SPRINGS AR
71901
US

IV. Provider business mailing address

2908 HAWKINS DRIVE
SEARCY AR
72143
US

V. Phone/Fax

Practice location:
  • Phone: 501-624-5238
  • Fax: 501-624-2519
Mailing address:
  • Phone: 501-305-3153
  • Fax: 501-279-3796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number681
License Number StateAR

VIII. Authorized Official

Name: JOEY MARTIN WIGGINS
Title or Position: PRESIDENT
Credential:
Phone: 501-305-3153