Healthcare Provider Details

I. General information

NPI: 1659956514
Provider Name (Legal Business Name): WEST DIXON ROAD ALF OPERATING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2021
Last Update Date: 08/12/2021
Certification Date: 08/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2821 W DIXON RD
LITTLE ROCK AR
72206-4256
US

IV. Provider business mailing address

317 MONMOUTH AVE STE 201
LAKEWOOD NJ
08701-3209
US

V. Phone/Fax

Practice location:
  • Phone: 501-888-4080
  • Fax:
Mailing address:
  • Phone: 848-210-2175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: YISROEL GANZ
Title or Position: INCORPORATOR
Credential:
Phone: 732-523-2395