Provider Demographics
NPI:1467437087
Name:MOUNTAINCREST REHAB SERVICES
Entity Type:Organization
Organization Name:MOUNTAINCREST REHAB SERVICES
Other - Org Name:MOUNTAINCREST REHABILITATION
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:DAMARILLO
Authorized Official - Last Name:SEBAG
Authorized Official - Suffix:
Authorized Official - Credentials:RPT
Authorized Official - Phone:870-743-5573
Mailing Address - Street 1:PO BOX 841
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72602-0841
Mailing Address - Country:US
Mailing Address - Phone:870-743-5573
Mailing Address - Fax:870-743-5974
Practice Address - Street 1:816 N MAIN ST
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-2915
Practice Address - Country:US
Practice Address - Phone:870-743-5573
Practice Address - Fax:870-743-5974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-07
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5C311OtherBLUE CROSS BLUE SHIELD
AR5C311Medicare ID - Type Unspecified