Healthcare Provider Details

I. General information

NPI: 1104814383
Provider Name (Legal Business Name): HAZEL STREET NURSING ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 07/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6811 S HAZEL ST
PINE BLUFF AR
71603-7829
US

IV. Provider business mailing address

6811 S HAZEL ST
PINE BLUFF AR
71603-7829
US

V. Phone/Fax

Practice location:
  • Phone: 870-535-1155
  • Fax: 870-535-0732
Mailing address:
  • Phone: 870-535-1155
  • Fax: 870-535-0732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number725
License Number StateAR

VIII. Authorized Official

Name: MICHAEL T SHEPARD
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 870-541-0342