Provider Demographics
NPI:1407933674
Name:ARKANSAS ELDER OUTREACH OF LITTLE ROCK, INC.
Entity Type:Organization
Organization Name:ARKANSAS ELDER OUTREACH OF LITTLE ROCK, INC.
Other - Org Name:THE BROADWAY NURSING AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:QUIBODEAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-769-7960
Mailing Address - Street 1:7534 HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:LA
Mailing Address - Zip Code:70374-3437
Mailing Address - Country:US
Mailing Address - Phone:985-532-1011
Mailing Address - Fax:985-532-1015
Practice Address - Street 1:7534 HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:LA
Practice Address - Zip Code:70374-3437
Practice Address - Country:US
Practice Address - Phone:985-532-1011
Practice Address - Fax:985-532-1015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA989314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1515612Medicaid
LA19-5583Medicare UPIN