Provider Demographics
NPI:1376562660
Name:MEDI-HOME, INC
Entity Type:Organization
Organization Name:MEDI-HOME, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:IMELDIA
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:RUSHER
Authorized Official - Suffix:
Authorized Official - Credentials:LPN ADM
Authorized Official - Phone:479-452-1541
Mailing Address - Street 1:4623 ROGERS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-4623
Mailing Address - Country:US
Mailing Address - Phone:479-452-1541
Mailing Address - Fax:479-452-2589
Practice Address - Street 1:4623 ROGERS AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-4623
Practice Address - Country:US
Practice Address - Phone:479-452-1541
Practice Address - Fax:479-452-2589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR045314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR045364Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER