Healthcare Provider Details

I. General information

NPI: 1003280454
Provider Name (Legal Business Name): MINE CREEK HOLDINGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2015
Last Update Date: 02/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 N MAIN ST
NASHVILLE AR
71852-3733
US

IV. Provider business mailing address

1407 N MAIN ST
NASHVILLE AR
71852-3733
US

V. Phone/Fax

Practice location:
  • Phone: 870-455-1008
  • Fax: 870-845-5280
Mailing address:
  • Phone: 870-455-1008
  • Fax: 870-845-5280

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1098
License Number StateAR

VIII. Authorized Official

Name: JOSEPH SCHWARTZ
Title or Position: MANAGER
Credential:
Phone: 201-635-1195