Healthcare Provider Details

I. General information

NPI: 1275673642
Provider Name (Legal Business Name): COUNTRYSIDE MANOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 02/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S THOMPSON RD
LAMAR AR
72846-9423
US

IV. Provider business mailing address

300 S THOMPSON RD
LAMAR AR
72846-9423
US

V. Phone/Fax

Practice location:
  • Phone: 479-754-2052
  • Fax: 479-754-5745
Mailing address:
  • Phone: 479-754-2052
  • Fax: 479-754-5745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number
License Number StateAR

VIII. Authorized Official

Name: JUSTIN PRICE
Title or Position: MEMBER
Credential:
Phone: 918-967-9285