Provider Demographics
NPI:1164748463
Name:BENTONVILLE ASSISTED LIVING SERVICES
Entity Type:Organization
Organization Name:BENTONVILLE ASSISTED LIVING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:C
Authorized Official - Last Name:OPPENHEIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-426-6510
Mailing Address - Street 1:808 N MAIN ST APT 1
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72712-4830
Mailing Address - Country:US
Mailing Address - Phone:479-273-7344
Mailing Address - Fax:479-464-7169
Practice Address - Street 1:3317 SE L ST
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-3793
Practice Address - Country:US
Practice Address - Phone:479-254-8759
Practice Address - Fax:479-254-9349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-12
Last Update Date:2010-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR180230794310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR180230794Medicaid