=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518517127
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEACHTREE VILLAGE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2019
-----------------------------------------------------
Last Update Date | 09/16/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1500 FRESNO ST
-----------------------------------------------------
City | FORT SMITH
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72901-7023
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-785-5544
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24068 E 785 RD
-----------------------------------------------------
City | WELLING
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74471-2356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-200-3049
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPERATING MANAGER
-----------------------------------------------------
Name | JANET LYNN NORDLIE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 719-200-3049
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------