Provider Demographics
NPI:1346260270
Name:ST. BERNARDS VILLAGE, INC.
Entity Type:Organization
Organization Name:ST. BERNARDS VILLAGE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:V.P. - SENIOR SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:HODGES
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:870-932-8141
Mailing Address - Street 1:1606 HEERN DR
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-5098
Mailing Address - Country:US
Mailing Address - Phone:870-972-4166
Mailing Address - Fax:870-972-1749
Practice Address - Street 1:1606 HEERN DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-5098
Practice Address - Country:US
Practice Address - Phone:870-972-4166
Practice Address - Fax:870-972-1749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR354310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR134880732Medicaid