Provider Demographics
NPI:1487667655
Name:MONTGOMERY COUNTY NURSING HOME
Entity Type:Organization
Organization Name:MONTGOMERY COUNTY NURSING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:FREDRICK
Authorized Official - Last Name:WANN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-867-2156
Mailing Address - Street 1:PO BOX 1208
Mailing Address - Street 2:
Mailing Address - City:MOUNT IDA
Mailing Address - State:AR
Mailing Address - Zip Code:71957-1208
Mailing Address - Country:US
Mailing Address - Phone:870-867-2156
Mailing Address - Fax:870-867-2049
Practice Address - Street 1:741 S DR
Practice Address - Street 2:
Practice Address - City:MOUNT IDA
Practice Address - State:AR
Practice Address - Zip Code:71957-1208
Practice Address - Country:US
Practice Address - Phone:870-867-2156
Practice Address - Fax:870-867-2049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR198314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR045266Medicare Oscar/Certification