Provider Demographics
NPI:1033424833
Name:CLARKSVILLE COMMUNITY HEALTH & REHABILITATION LLC
Entity Type:Organization
Organization Name:CLARKSVILLE COMMUNITY HEALTH & REHABILITATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:V
Authorized Official - Last Name:KEMPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-598-9586
Mailing Address - Street 1:9785 CROSSPOINT BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-3321
Mailing Address - Country:US
Mailing Address - Phone:317-598-9467
Mailing Address - Fax:317-845-0616
Practice Address - Street 1:400 OAK CT
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:AR
Practice Address - Zip Code:72830-3778
Practice Address - Country:US
Practice Address - Phone:317-841-2377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-17
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
314000000X
AR945314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR186044311Medicaid