Healthcare Provider Details

I. General information

NPI: 1386732030
Provider Name (Legal Business Name): PINE RIDGE HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 S BAY ST
PINE BLUFF AR
71603-3040
US

IV. Provider business mailing address

1005 MCLAIN ST
NEWPORT AR
72112-3529
US

V. Phone/Fax

Practice location:
  • Phone: 870-535-8878
  • Fax: 870-535-0640
Mailing address:
  • Phone: 870-523-4333
  • Fax: 870-523-4341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number801
License Number StateAR

VIII. Authorized Official

Name: MR. RICK D SAMPSON
Title or Position: AGENT
Credential:
Phone: 870-523-4333