Provider Demographics
NPI:1073578720
Name:WALDRON NURSING CENTER,INC.
Entity Type:Organization
Organization Name:WALDRON NURSING CENTER,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:
Authorized Official - Last Name:WATTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-637-3171
Mailing Address - Street 1:1369 W 6TH ST
Mailing Address - Street 2:PO BOX 2230
Mailing Address - City:WALDRON
Mailing Address - State:AR
Mailing Address - Zip Code:72958-7642
Mailing Address - Country:US
Mailing Address - Phone:479-637-3171
Mailing Address - Fax:
Practice Address - Street 1:1369 W 6TH ST
Practice Address - Street 2:
Practice Address - City:WALDRON
Practice Address - State:AR
Practice Address - Zip Code:72958-7642
Practice Address - Country:US
Practice Address - Phone:479-637-3171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR646314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR199657311Medicaid
AR199657311Medicaid