Healthcare Provider Details

I. General information

NPI: 1336228394
Provider Name (Legal Business Name): MEDICALODGES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1625 E 42ND ST
TEXARKANA AR
71854-1654
US

IV. Provider business mailing address

1625 E 42ND ST
TEXARKANA AR
71854-1654
US

V. Phone/Fax

Practice location:
  • Phone: 870-772-0689
  • Fax: 870-772-1103
Mailing address:
  • Phone: 870-772-0689
  • Fax: 870-772-1103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number427
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number427
License Number StateAR

VIII. Authorized Official

Name: MS. CATHY W FISHER
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 620-251-6700