Healthcare Provider Details

I. General information

NPI: 1215444963
Provider Name (Legal Business Name): SOULS HARBOR OF ROGERS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2018
Last Update Date: 01/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1206 N 2ND ST
ROGERS AR
72756-2836
US

IV. Provider business mailing address

1206 N 2ND ST
ROGERS AR
72756-2836
US

V. Phone/Fax

Practice location:
  • Phone: 479-640-4225
  • Fax:
Mailing address:
  • Phone: 479-640-4225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateAR

VIII. Authorized Official

Name: CHARLENE FIELDS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 479-640-4225