Provider Demographics
NPI:1184631202
Name:STAR CITY NURSING CENTER, PLLC
Entity Type:Organization
Organization Name:STAR CITY NURSING CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MBR/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:HEAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-628-4295
Mailing Address - Street 1:505 E VICTORY ST
Mailing Address - Street 2:
Mailing Address - City:STAR CITY
Mailing Address - State:AR
Mailing Address - Zip Code:71667-5327
Mailing Address - Country:US
Mailing Address - Phone:870-628-4295
Mailing Address - Fax:870-628-5316
Practice Address - Street 1:505 E VICTORY ST
Practice Address - Street 2:
Practice Address - City:STAR CITY
Practice Address - State:AR
Practice Address - Zip Code:71667-5327
Practice Address - Country:US
Practice Address - Phone:870-628-4295
Practice Address - Fax:870-628-5316
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR0704314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR0704OtherLIC. #
AR157584311Medicaid
AR0704OtherLIC. #