Provider Demographics
NPI:1588833974
Name:PRAIRIE GROVE HEALTH AND REHABILITATION
Entity Type:Organization
Organization Name:PRAIRIE GROVE HEALTH AND REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:RYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-410-1740
Mailing Address - Street 1:8520 S 36TH TER
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72908-8880
Mailing Address - Country:US
Mailing Address - Phone:479-410-1740
Mailing Address - Fax:
Practice Address - Street 1:621 S MOCK ST
Practice Address - Street 2:
Practice Address - City:PRAIRIE GROVE
Practice Address - State:AR
Practice Address - Zip Code:72753-3146
Practice Address - Country:US
Practice Address - Phone:479-846-2169
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-29
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR853314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR166574311Medicaid
AR166574311Medicaid