Provider Demographics
NPI:1427539600
Name:PEACHTREE VILLAGE OF FARMINGTON, LLC
Entity Type:Organization
Organization Name:PEACHTREE VILLAGE OF FARMINGTON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:NORDLIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:719-200-3049
Mailing Address - Street 1:24068 E 785 RD
Mailing Address - Street 2:
Mailing Address - City:WELLING
Mailing Address - State:OK
Mailing Address - Zip Code:74471-2356
Mailing Address - Country:US
Mailing Address - Phone:719-200-3049
Mailing Address - Fax:
Practice Address - Street 1:55 W RAINSONG ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:AR
Practice Address - Zip Code:72730-8635
Practice Address - Country:US
Practice Address - Phone:479-267-3335
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR054310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility