Provider Demographics
NPI:1174802888
Name:WENTWORTH LLC
Entity type:Organization
Organization Name:WENTWORTH LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ROSS
Authorized Official - Middle Name:
Authorized Official - Last Name:PONTHIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-443-8167
Mailing Address - Street 1:26 WARNOCK SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71753-9000
Mailing Address - Country:US
Mailing Address - Phone:870-234-1361
Mailing Address - Fax:870-234-4267
Practice Address - Street 1:26 WARNOCK SPRINGS RD
Practice Address - Street 2:
Practice Address - City:MAGNOLIA
Practice Address - State:AR
Practice Address - Zip Code:71753-9000
Practice Address - Country:US
Practice Address - Phone:870-234-1361
Practice Address - Fax:870-234-4267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-11
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA045187Medicare Oscar/Certification