=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518120740
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEACHTREE MENA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2008
-----------------------------------------------------
Last Update Date | 07/08/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1803 CORDIE DR
-----------------------------------------------------
City | MENA
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71953-9340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-394-2600
-----------------------------------------------------
Fax | 870-540-0012
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1803 CORDIE DR
-----------------------------------------------------
City | MENA
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71953-9340
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-394-2600
-----------------------------------------------------
Fax | 870-540-0012
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | MR. MICHAEL THOMAS SHEPARD I
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 501-276-8883
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------