=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770537565
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRYSTAL FALLS HEALTHCARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2006
-----------------------------------------------------
Last Update Date | 03/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1206 W COLLIN RAYE DR
-----------------------------------------------------
City | DE QUEEN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71832-2030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-642-3317
-----------------------------------------------------
Fax | 870-642-6667
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1206 W COLLIN RAYE DR
-----------------------------------------------------
City | DE QUEEN
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71832-2030
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-642-3317
-----------------------------------------------------
Fax | 870-642-6667
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REGIONAL BUSINESS OFFICE MANAGER
-----------------------------------------------------
Name | MRS. DEBBIE J PERRON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 501-888-4200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 796
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------