MEDICARE: HERITAGE SQUARE NURSING AND REHABILITATION CENTER, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	672	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1043206360
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HERITAGE SQUARE NURSING AND REHABILITATION CENTER, INC.

Provider Business Mailing Address
First Line	:	710 N RUDDLE RD
Second Line	:
City	:	BLYTHEVILLE
State	:	AR
Zip	:	72315-2137
Country	:	US
Telephone Number	:	870-763-3654
Fax Number	:	870-762-1172

Provider Business Practice Location Address
First Line	:	710 N RUDDLE RD
Second Line	:
City	:	BLYTHEVILLE
State	:	AR
Zip	:	72315-2137
Country	:	US
Telephone Number	:	870-763-3654
Fax Number	:	870-762-1172

Authorized Official
Title or Position	:	PRESIDENT
Name	:	A BRANDON ADAMS
Credential	:
Telephone Number	:	501-932-0050

Provider Enumeration Date	:	09/22/2005
Last Update Date	:	06/30/2016

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