Healthcare Provider Details

I. General information

NPI: 1659705010
Provider Name (Legal Business Name): MINE CREEK HEALTH AND REHAB, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2013
Last Update Date: 08/21/2013
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

1422 CLARKVIEW RD
BALTIMORE MD
21209-2385
US

V. Phone/Fax

Practice location:
  • Phone: 870-845-2012
  • Fax:
Mailing address:
  • Phone: 410-342-3155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number776
License Number StateAR

VIII. Authorized Official

Name: MR. DANIEL BAIRD
Title or Position: MANAGER
Credential:
Phone: 410-342-3155