Healthcare Provider Details

I. General information

NPI: 1467780510
Provider Name (Legal Business Name): MADISON RESIDENTIAL CARE FACILITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2009
Last Update Date: 12/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2821 W DIXON RD
LITTLE ROCK AR
72206-4256
US

IV. Provider business mailing address

2821 W DIXON RD
LITTLE ROCK AR
72206-4256
US

V. Phone/Fax

Practice location:
  • Phone: 501-888-4080
  • Fax: 501-486-9119
Mailing address:
  • Phone: 501-888-4080
  • Fax: 501-486-9119

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number041
License Number StateAR

VIII. Authorized Official

Name: MR. SY NIKSEFAT
Title or Position: OWNER
Credential:
Phone: 501-888-4080