Provider Demographics
NPI:1558777953
Name:FORDYCE ASSISTED LIVING INC
Entity Type:Organization
Organization Name:FORDYCE ASSISTED LIVING INC
Other - Org Name:DALTONS PLACE AT FORDYCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:D
Authorized Official - Last Name:TENBROOK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-394-3200
Mailing Address - Street 1:1718 INDUSTRIAL DR
Mailing Address - Street 2:
Mailing Address - City:FORDYCE
Mailing Address - State:AR
Mailing Address - Zip Code:71742
Mailing Address - Country:US
Mailing Address - Phone:870-890-2408
Mailing Address - Fax:870-890-2420
Practice Address - Street 1:1718 INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:FORDYCE
Practice Address - State:AR
Practice Address - Zip Code:71074
Practice Address - Country:US
Practice Address - Phone:870-890-2412
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-07
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR097310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility