Healthcare Provider Details

I. General information

NPI: 1265520167
Provider Name (Legal Business Name): MEDICALODGES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 06/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1621 E 42ND ST
TEXARKANA AR
71854-1654
US

IV. Provider business mailing address

1621 E 42ND ST
TEXARKANA AR
71854-1654
US

V. Phone/Fax

Practice location:
  • Phone: 870-774-3581
  • Fax: 870-773-2802
Mailing address:
  • Phone: 870-774-3581
  • Fax: 870-773-2802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number219
License Number StateAZ

VIII. Authorized Official

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