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General NPI Number Information
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NPI Number | 1760627640
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Entity Type | Organization
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Legal Business Name | CAVHS
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Dates
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Enumeration Date | 12/08/2008
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Last Update Date | 12/08/2008
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Provider Practice Location Address
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Address Line | 2220 FT ROOTS DRIVE
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City | NORTH LITTLE ROCK
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State | AR
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Zip | 72114-1706
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Country | US
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Telephone | 501-257-3469
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Fax |
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Provider Business Mailing Address
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Address Line | 2220 FT. ROOTS DRIVE 116B NLR
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City | NORTH LITTLE ROCK
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State | AR
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Zip | 72114-1706
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Country | US
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Telephone | 501-257-3469
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Fax |
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Authorized Official
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Title or Position | CERT. RECREATION THERAPIST
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Name | SUSAN LEIGH BRADLEY
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Credential | CTRS
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Telephone | 501-257-3469
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 313M00000X
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Taxonomy Name | Nursing Facility/Intermediate Care Facility
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License Number | CERT. ID # 22745
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 22745
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License Number State | NY
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