Healthcare Provider Details

I. General information

NPI: 1427894567
Provider Name (Legal Business Name): LAKE VILLAGE OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/08/2024
Last Update Date: 03/11/2026
Certification Date: 03/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

903 BORGOGNONI DR
LAKE VILLAGE AR
71653-1623
US

IV. Provider business mailing address

903 BORGOGNONI DR
LAKE VILLAGE AR
71653-1623
US

V. Phone/Fax

Practice location:
  • Phone: 870-265-5337
  • Fax:
Mailing address:
  • Phone: 870-265-5337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: JOHN F PONTHIE
Title or Position: MEMBER
Credential:
Phone: 318-216-3316