Healthcare Provider Details

I. General information

NPI: 1134820541
Provider Name (Legal Business Name): MAIN STREET OPERATING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2023
Last Update Date: 11/16/2023
Certification Date: 11/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2010 MAIN ST
VAN BUREN AR
72956-4957
US

IV. Provider business mailing address

1999 CEDARBRIDGE AVE STE 3B
LAKEWOOD NJ
08701-6915
US

V. Phone/Fax

Practice location:
  • Phone: 479-474-6885
  • Fax:
Mailing address:
  • Phone: 732-366-5705
  • Fax:

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: ISRAEL GANZ
Title or Position: DIRECTOR
Credential:
Phone: 732-366-5705