Healthcare Provider Details

I. General information

NPI: 1558697227
Provider Name (Legal Business Name): MALCBNDR581, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2009
Last Update Date: 11/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6411 VALLEY RANCH DR
LITTLE ROCK AR
72223
US

IV. Provider business mailing address

PO BOX 3376
RIDGELAND MS
39158-3376
US

V. Phone/Fax

Practice location:
  • Phone: 601-853-2667
  • Fax: 601-853-2116
Mailing address:
  • Phone: 601-853-2667
  • Fax: 601-853-2116

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: MR. DAVID ROTOLO
Title or Position: MEMBER
Credential:
Phone: 601-853-2667