Provider Demographics
NPI:1225139637
Name:ALLEGIANCE SPECIALTY HOSPITAL OF LITTLE ROCK, LLC
Entity Type:Organization
Organization Name:ALLEGIANCE SPECIALTY HOSPITAL OF LITTLE ROCK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROCK
Authorized Official - Middle Name:
Authorized Official - Last Name:BORDELON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-629-5321
Mailing Address - Street 1:504 TEXAS ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-3526
Mailing Address - Country:US
Mailing Address - Phone:318-226-2802
Mailing Address - Fax:318-226-8205
Practice Address - Street 1:11401 INTERSTATE 30 FL 2
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72209-7042
Practice Address - Country:US
Practice Address - Phone:501-455-7300
Practice Address - Fax:501-601-1333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR4374282E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282E00000XHospitalsLong Term Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR163089105Medicaid
AR042010Medicare Oscar/Certification