Provider Demographics
NPI:1174030860
Name:THRIVE PEDIATRIC NURSING INC
Entity Type:Organization
Organization Name:THRIVE PEDIATRIC NURSING INC
Other - Org Name:THRIVE AT HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MANTUANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-247-6131
Mailing Address - Street 1:7197 SHERIDAN RD STE 105
Mailing Address - Street 2:
Mailing Address - City:WHITE HALL
Mailing Address - State:AR
Mailing Address - Zip Code:71602-3261
Mailing Address - Country:US
Mailing Address - Phone:870-247-6131
Mailing Address - Fax:
Practice Address - Street 1:7197 SHERIDAN RD STE 105
Practice Address - Street 2:
Practice Address - City:WHITE HALL
Practice Address - State:AR
Practice Address - Zip Code:71602-3261
Practice Address - Country:US
Practice Address - Phone:870-247-6131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-04
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR5369251E00000X
251E00000X, 251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARAR5480OtherCLASS A AND B DERIVITIVE
AR224683738Medicaid
AR235534514Medicaid
ARAR5648OtherCLASS B (NEW)
ARAR5369OtherARKANSAS HOME HEALTH CLASS B
ARAR5480OtherCLASS A AND B DERIVITIVE