Healthcare Provider Details

I. General information

NPI: 1073795936
Provider Name (Legal Business Name): OLOTOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2007
Last Update Date: 06/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1393 DON TYSON BLVD
SPRINGDALE AR
72764
US

IV. Provider business mailing address

14 PROFESSIONAL PKWY SUITE A
RIDGELAND MS
39157-4190
US

V. Phone/Fax

Practice location:
  • Phone: 479-751-2390
  • Fax:
Mailing address:
  • Phone: 601-853-2605
  • Fax: 601-853-2116

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: MR. DEAN DRANGUET
Title or Position: OFFICE MANAGER
Credential:
Phone: 601-853-2605