=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447698972
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HOMETOWN HEALTHCARE OF ELKINS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2013
-----------------------------------------------------
Last Update Date | 05/15/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4252 CROSSOVER
-----------------------------------------------------
City | FAYETTEVILLLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72703-2936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-310-8197
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 847 KENSINGTON CV
-----------------------------------------------------
City | SPRINGDALE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72762-6286
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-530-5092
-----------------------------------------------------
Fax | 479-361-8009
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ OPERATOR
-----------------------------------------------------
Name | MRS. KAREN C REYNOLDS
-----------------------------------------------------
Credential | APN
-----------------------------------------------------
Telephone | 479-530-5092
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 04D2045431
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------