Healthcare Provider Details

I. General information

NPI: 1215676903
Provider Name (Legal Business Name): SOUTHERN PINES HEALTH OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2022
Last Update Date: 08/09/2023
Certification Date: 08/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 MANOR RD
PRESCOTT AR
71857-2800
US

IV. Provider business mailing address

PO BOX 8250
SEARCY AR
72145-8250
US

V. Phone/Fax

Practice location:
  • Phone: 870-455-1086
  • Fax: 870-887-6690
Mailing address:
  • Phone: 501-254-0007
  • Fax: 888-866-9887

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: ETHAN DREIFUS
Title or Position: AUTHORIZED SIGNATORY
Credential:
Phone: 501-961-8100