Healthcare Provider Details

I. General information

NPI: 1962708149
Provider Name (Legal Business Name): REGIONAL CARE OF LEBANON NORTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2011
Last Update Date: 11/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

596 MORTON RD
LEBANON MO
65536-3648
US

IV. Provider business mailing address

222 S 1ST ST
ROGERS AR
72756-4504
US

V. Phone/Fax

Practice location:
  • Phone: 417-532-9173
  • Fax: 417-532-8223
Mailing address:
  • Phone: 479-464-0200
  • Fax: 479-464-8098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number037775
License Number StateMO

VIII. Authorized Official

Name: MR. PHILLIP CODY LONG
Title or Position: CFO
Credential:
Phone: 479-464-0200