Healthcare Provider Details

I. General information

NPI: 1205119641
Provider Name (Legal Business Name): PARK HERITAGE NURSING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2011
Last Update Date: 09/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1513 S DIXIELAND RD
ROGERS AR
72758-4935
US

IV. Provider business mailing address

1513 S DIXIELAND RD
ROGERS AR
72758-4935
US

V. Phone/Fax

Practice location:
  • Phone: 479-636-5841
  • Fax: 479-621-8345
Mailing address:
  • Phone: 479-636-5841
  • Fax: 479-621-8345

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: BOYD GENTRY
Title or Position: PRESIDENT & CEO
Credential:
Phone: 937-964-8974