Healthcare Provider Details

I. General information

NPI: 1548893498
Provider Name (Legal Business Name): PACC SENIOR CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2020
Last Update Date: 10/26/2023
Certification Date: 10/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2908 KING ST
JONESBORO AR
72401-5321
US

IV. Provider business mailing address

2908 KING ST
JONESBORO AR
72401-5321
US

V. Phone/Fax

Practice location:
  • Phone: 870-933-6247
  • Fax: 870-933-6446
Mailing address:
  • Phone: 870-933-9247
  • Fax: 870-933-6446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: PAUL FRY
Title or Position: OWNER
Credential:
Phone: 708-933-6247