Healthcare Provider Details

I. General information

NPI: 1174802888
Provider Name (Legal Business Name): WENTWORTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2011
Last Update Date: 09/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26 WARNOCK SPRINGS RD
MAGNOLIA AR
71753-9000
US

IV. Provider business mailing address

26 WARNOCK SPRINGS RD
MAGNOLIA AR
71753-9000
US

V. Phone/Fax

Practice location:
  • Phone: 870-234-1361
  • Fax: 870-234-4267
Mailing address:
  • Phone: 870-234-1361
  • Fax: 870-234-4267

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: ROSS PONTHIE
Title or Position: MEMBER
Credential:
Phone: 318-443-8167