Healthcare Provider Details

I. General information

NPI: 1922096593
Provider Name (Legal Business Name): DIVERSICARE PINEDALE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1311 N PECAN ST
NEWPORT AR
72112-2816
US

IV. Provider business mailing address

1311 N PECAN ST
NEWPORT AR
72112-2816
US

V. Phone/Fax

Practice location:
  • Phone: 870-523-9514
  • Fax: 870-523-8198
Mailing address:
  • Phone: 870-523-9514
  • Fax: 870-523-8198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number654
License Number StateAR

VIII. Authorized Official

Name: RAYMOND L. TYLER JR.
Title or Position: EXECUTIVE VICE PRESIDENT AND COO
Credential:
Phone: 615-771-7575