Provider Demographics
NPI:1538111398
Name:RUSSELLVILLE HOLDINGS LLC
Entity Type:Organization
Organization Name:RUSSELLVILLE HOLDINGS LLC
Other - Org Name:ST. MARY'S REGIONAL MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:TERRANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:DILLON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-596-7220
Mailing Address - Street 1:PO BOX 849117
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-9117
Mailing Address - Country:US
Mailing Address - Phone:479-968-2841
Mailing Address - Fax:479-968-8189
Practice Address - Street 1:1808 W MAIN ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2724
Practice Address - Country:US
Practice Address - Phone:479-968-2841
Practice Address - Fax:479-968-8189
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RUSSELLVILLE HOLDINGS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-17
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4193314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR152329105Medicaid
045320Medicare Oscar/Certification