Healthcare Provider Details

I. General information

NPI: 1558634683
Provider Name (Legal Business Name): NORTHRIDGE HC&R NURSING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2012
Last Update Date: 05/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 JOHN ASHLEY DR
NORTH LITTLE ROCK AR
72114-1815
US

IV. Provider business mailing address

2501 JOHN ASHLEY DR
NORTH LITTLE ROCK AR
72114-1815
US

V. Phone/Fax

Practice location:
  • Phone: 501-758-3800
  • Fax: 501-758-2276
Mailing address:
  • Phone: 501-758-3800
  • Fax: 501-758-2276

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: BOYD P GENTRY
Title or Position: PRESIDENT & CEO
Credential:
Phone: 937-964-8974