Provider Demographics
NPI:1598775686
Name:WEST MEMPHIS HEALTHCARE CENTER, LLC
Entity Type:Organization
Organization Name:WEST MEMPHIS HEALTHCARE CENTER, LLC
Other - Org Name:BROADWAY HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:BUTTERWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-527-4083
Mailing Address - Street 1:11350 MCCORMICK RD
Mailing Address - Street 2:EXECUTIVE PLAZA 3, SUITE 503
Mailing Address - City:HUNT VALLEY
Mailing Address - State:MD
Mailing Address - Zip Code:21031-1002
Mailing Address - Country:US
Mailing Address - Phone:410-527-4083
Mailing Address - Fax:410-527-4081
Practice Address - Street 1:800 WEST BROADWAY
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301
Practice Address - Country:US
Practice Address - Phone:870-735-5174
Practice Address - Fax:870-735-0516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR154008311Medicaid
045195Medicare ID - Type Unspecified