Provider Demographics
NPI:1528014487
Name:MURFREESBORO NURSING CENTER, LLC
Entity Type:Organization
Organization Name:MURFREESBORO NURSING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:TIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-285-2186
Mailing Address - Street 1:PO BOX 656
Mailing Address - Street 2:
Mailing Address - City:MURFREESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:71958-0656
Mailing Address - Country:US
Mailing Address - Phone:870-285-2186
Mailing Address - Fax:
Practice Address - Street 1:110 W 13TH ST
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:AR
Practice Address - Zip Code:71958-9501
Practice Address - Country:US
Practice Address - Phone:870-285-2186
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR548313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR045415Medicare Oscar/Certification