Provider Demographics
NPI:1043743768
Name:PEACHTREE VILLAGE AT HOLIDAY ISLAND
Entity Type:Organization
Organization Name:PEACHTREE VILLAGE AT HOLIDAY ISLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:L
Authorized Official - Last Name:NORDLIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-200-3049
Mailing Address - Street 1:5 PARK DR
Mailing Address - Street 2:
Mailing Address - City:HOLIDAY ISLAND
Mailing Address - State:AR
Mailing Address - Zip Code:72631-9388
Mailing Address - Country:US
Mailing Address - Phone:479-253-9933
Mailing Address - Fax:
Practice Address - Street 1:5 PARK DR
Practice Address - Street 2:
Practice Address - City:HOLIDAY ISLAND
Practice Address - State:AR
Practice Address - Zip Code:72631-9388
Practice Address - Country:US
Practice Address - Phone:479-253-9933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-10
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR002310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility