Provider Demographics
NPI:1508251786
Name:GRAND MANOR
Entity Type:Organization
Organization Name:GRAND MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:HELMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-412-4400
Mailing Address - Street 1:1960 HIGHWAY 425 N
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:AR
Mailing Address - Zip Code:71655-8862
Mailing Address - Country:US
Mailing Address - Phone:870-412-4400
Mailing Address - Fax:870-412-4506
Practice Address - Street 1:1960 HIGHWAY 425 N
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655-8862
Practice Address - Country:US
Practice Address - Phone:870-412-4400
Practice Address - Fax:870-412-4506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-03
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR106261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR206724794Medicaid