Provider Demographics
NPI:1558697227
Name:MALCBNDR581, LLC
Entity Type:Organization
Organization Name:MALCBNDR581, LLC
Other - Org Name:VALLEY RANCH NURSING & REHAB CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTOLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-853-2667
Mailing Address - Street 1:PO BOX 3376
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39158-3376
Mailing Address - Country:US
Mailing Address - Phone:601-853-2667
Mailing Address - Fax:601-853-2116
Practice Address - Street 1:6411 VALLEY RANCH DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72223
Practice Address - Country:US
Practice Address - Phone:601-853-2667
Practice Address - Fax:601-853-2116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-30
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR045431OtherMEDICARE PTAN