Provider Demographics
NPI:1003280454
Name:MINE CREEK HOLDINGS LLC
Entity Type:Organization
Organization Name:MINE CREEK HOLDINGS LLC
Other - Org Name:MINE CREEK HEALTH AND REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHWARTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:201-635-1195
Mailing Address - Street 1:1407 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:71852-3733
Mailing Address - Country:US
Mailing Address - Phone:870-455-1008
Mailing Address - Fax:870-845-5280
Practice Address - Street 1:1407 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:AR
Practice Address - Zip Code:71852-3733
Practice Address - Country:US
Practice Address - Phone:870-455-1008
Practice Address - Fax:870-845-5280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-23
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1098314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR211197311Medicaid
045180Medicare Oscar/Certification