Healthcare Provider Details

I. General information

NPI: 1194540534
Provider Name (Legal Business Name): SHORT MOUNTAIN LODGE CSSP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2024
Last Update Date: 05/07/2025
Certification Date: 05/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2721 W WALNUT ST
PARIS AR
72855-3642
US

IV. Provider business mailing address

6500 RYE HILL RD E
FORT SMITH AR
72916-8397
US

V. Phone/Fax

Practice location:
  • Phone: 479-963-2255
  • Fax:
Mailing address:
  • Phone: 479-650-7083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. CLAUDE BRYANT
Title or Position: REGIONAL ADMINISTRATOR
Credential:
Phone: 479-650-7083