Healthcare Provider Details

I. General information

NPI: 1114485471
Provider Name (Legal Business Name): SHORT MOUNTAIN LODGE RESIDENTIAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2019
Last Update Date: 03/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2721 W WALNUT ST
PARIS AR
72855-3642
US

IV. Provider business mailing address

2721 W WALNUT ST
PARIS AR
72855-3642
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: LINDA SHORT
Title or Position: OWNER
Credential:
Phone: 479-452-4949