MEDICARE: PEACHTREE VILLAGE, LLC

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	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1518517127
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEACHTREE VILLAGE, LLC

Provider Business Mailing Address
First Line	:	24068 E 785 RD
Second Line	:
City	:	WELLING
State	:	OK
Zip	:	74471-2356
Country	:	US
Telephone Number	:	719-200-3049
Fax Number	:

Provider Business Practice Location Address
First Line	:	1500 FRESNO ST
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72901-7023
Country	:	US
Telephone Number	:	479-785-5544
Fax Number	:

Authorized Official
Title or Position	:	OPERATING MANAGER
Name	:	JANET LYNN NORDLIE
Credential	:
Telephone Number	:	719-200-3049

Provider Enumeration Date	:	09/16/2019
Last Update Date	:	09/16/2019

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