Healthcare Provider Details

I. General information

NPI: 1245310440
Provider Name (Legal Business Name): INNISFREE NURSING & REHABILITATION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 S 24TH ST
ROGERS AR
72758-1116
US

IV. Provider business mailing address

301 S 24TH ST
ROGERS AR
72758-1116
US

V. Phone/Fax

Practice location:
  • Phone: 479-636-5545
  • Fax: 479-621-9095
Mailing address:
  • Phone: 479-636-5545
  • Fax: 479-621-9095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number552
License Number StateAR

VIII. Authorized Official

Name: JOHN B MONTGOMERY
Title or Position: OWNER
Credential:
Phone: 479-636-5545