Provider Demographics
NPI:1386678696
Name:REGIONAL CARE OF JACKSONVILLE, LLC
Entity Type:Organization
Organization Name:REGIONAL CARE OF JACKSONVILLE, LLC
Other - Org Name:WOODLAND HILLS HEALTHCARE AND REHABILITATION OF JACKSONVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:KILGORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-464-0200
Mailing Address - Street 1:222 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-4504
Mailing Address - Country:US
Mailing Address - Phone:479-464-0200
Mailing Address - Fax:479-464-8098
Practice Address - Street 1:1320 BRADEN ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-3719
Practice Address - Country:US
Practice Address - Phone:501-241-2191
Practice Address - Fax:501-241-2197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR700314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR119706311Medicaid
045378Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER