MEDICARE: BEACON DRIVE INN OF BOONEVILLE,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	332B00000X	Durable Medical Equipment & Medical Supplies	013883	AR

General Provider Information

NPI Number	:	1356432082
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BEACON DRIVE INN OF BOONEVILLE,INC

Provider Business Mailing Address
First Line	:	415 ROGERS AVE
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72901-1903
Country	:	US
Telephone Number	:	479-782-0363
Fax Number	:	479-783-1188

Provider Business Practice Location Address
First Line	:	415 ROGERS AVE
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72901-1903
Country	:	US
Telephone Number	:	479-782-0363
Fax Number	:	479-783-1188

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. MICHAEL S MORTON
Credential	:
Telephone Number	:	479-783-4672

Provider Enumeration Date	:	09/27/2006
Last Update Date	:	03/17/2008

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