MEDICARE: MONTGOMERY COUNTY NURSING HOME

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	198	AR

General Provider Information

NPI Number	:	1487667655
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MONTGOMERY COUNTY NURSING HOME

Provider Business Mailing Address
First Line	:	PO BOX 1208
Second Line	:
City	:	MOUNT IDA
State	:	AR
Zip	:	71957-1208
Country	:	US
Telephone Number	:	870-867-2156
Fax Number	:	870-867-2049

Provider Business Practice Location Address
First Line	:	741 S DR
Second Line	:
City	:	MOUNT IDA
State	:	AR
Zip	:	71957-1208
Country	:	US
Telephone Number	:	870-867-2156
Fax Number	:	870-867-2049

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. BRYAN FREDRICK WANN
Credential	:
Telephone Number	:	870-867-2156

Provider Enumeration Date	:	08/15/2006
Last Update Date	:	08/22/2020

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Directions to “MONTGOMERY COUNTY NURSING HOME ” Practice Location

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