Healthcare Provider Details

I. General information

NPI: 1114247863
Provider Name (Legal Business Name): HOMETOWN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2010
Last Update Date: 06/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 SE LINDSEY ST
HOXIE AR
72433-2224
US

IV. Provider business mailing address

805 SE 7TH ST
WALNUT RIDGE AR
72476-3208
US

V. Phone/Fax

Practice location:
  • Phone: 870-886-1333
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. LANNY TINKER
Title or Position: OWNER
Credential:
Phone: 870-886-1333