Healthcare Provider Details

I. General information

NPI: 1962860445
Provider Name (Legal Business Name): COLONEL GLENN HEALTH AND REHAB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2016
Last Update Date: 05/28/2020
Certification Date: 05/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13700 DAVID O DODD RD
LITTLE ROCK AR
72210-2747
US

IV. Provider business mailing address

415 ROGERS AVE
FORT SMITH AR
72901-1903
US

V. Phone/Fax

Practice location:
  • Phone: 501-907-8200
  • Fax: 501-907-8205
Mailing address:
  • Phone: 479-783-4672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MR. MICHAEL S MORTON
Title or Position: MEMBER
Credential:
Phone: 479-783-4672