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General NPI Number Information
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NPI Number | 1700306107
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Entity Type | Organization
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Legal Business Name | NORTHWEST REGIONAL SUPPORTIVE LIVING LLC
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Dates
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Enumeration Date | 06/27/2017
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Last Update Date | 06/27/2017
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Provider Practice Location Address
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Address Line | 1400 OLD BERGMAN RD
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City | HARRISON
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State | AR
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Zip | 72601-3078
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Country | US
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Telephone | 870-204-5102
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 2568
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City | HARRISON
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State | AR
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Zip | 72602-2568
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Country | US
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Telephone | 870-204-5102
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | TODD PARKER HIGHTOWER
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Credential |
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Telephone | 479-471-9797
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | 430
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License Number State | AR
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