Provider Demographics
NPI:1609862911
Name:GNC OF STAR CITY INC
Entity Type:Organization
Organization Name:GNC OF STAR CITY INC
Other - Org Name:GARDNER NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:BRANDON
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-932-0050
Mailing Address - Street 1:824 SALEM RD
Mailing Address - Street 2:STE 210
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-4800
Mailing Address - Country:US
Mailing Address - Phone:501-932-0050
Mailing Address - Fax:501-832-0056
Practice Address - Street 1:702 N DREW ST
Practice Address - Street 2:
Practice Address - City:STAR CITY
Practice Address - State:AR
Practice Address - Zip Code:71667-5728
Practice Address - Country:US
Practice Address - Phone:870-628-4144
Practice Address - Fax:870-628-4891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-22
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR699314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR119704311Medicaid
AR119704311Medicaid