Healthcare Provider Details

I. General information

NPI: 1609862911
Provider Name (Legal Business Name): GNC OF STAR CITY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 07/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 N DREW ST
STAR CITY AR
71667-5728
US

IV. Provider business mailing address

824 SALEM RD STE 210
CONWAY AR
72034-4800
US

V. Phone/Fax

Practice location:
  • Phone: 870-628-4144
  • Fax: 870-628-4891
Mailing address:
  • Phone: 501-932-0050
  • Fax: 501-832-0056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number699
License Number StateAR

VIII. Authorized Official

Name: ANTHONY BRANDON ADAMS
Title or Position: OWNER/PRESIDENT
Credential:
Phone: 501-932-0050