Healthcare Provider Details

I. General information

NPI: 1871812099
Provider Name (Legal Business Name): PINE LANE THERAPY AND LIVING CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2010
Last Update Date: 07/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 PINETREE LN
MOUNTAIN HOME AR
72653-4502
US

IV. Provider business mailing address

1100 PINETREE LN
MOUNTAIN HOME AR
72653-4502
US

V. Phone/Fax

Practice location:
  • Phone: 870-425-6316
  • Fax: 870-425-5197
Mailing address:
  • Phone: 870-425-6316
  • Fax: 870-425-5197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number720
License Number StateAR

VIII. Authorized Official

Name: BOBBU HARGIS
Title or Position: PRESIDENT
Credential:
Phone: 870-368-4050