Provider Demographics
NPI:1376531202
Name:FCNRC, INC.
Entity Type:Organization
Organization Name:FCNRC, INC.
Other - Org Name:SOUTHFORK RIVER THERAPY & LIVING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SEC
Authorized Official - Prefix:
Authorized Official - First Name:JOHNIECE
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-368-4054
Mailing Address - Street 1:PO BOX 918
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:AR
Mailing Address - Zip Code:72556-0918
Mailing Address - Country:US
Mailing Address - Phone:870-895-3817
Mailing Address - Fax:870-368-4054
Practice Address - Street 1:624 HWY 62/412 WEST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:AR
Practice Address - Zip Code:72576
Practice Address - Country:US
Practice Address - Phone:870-895-3817
Practice Address - Fax:870-368-4054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-13
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR760314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR154017311Medicaid
AR154017311Medicaid