Provider Demographics
NPI:1619439825
Name:WILSON RESIDENTIAL CARE
Entity Type:Organization
Organization Name:WILSON RESIDENTIAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:870-295-3557
Mailing Address - Street 1:1679 HIGHWAY 243 S
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:AR
Mailing Address - Zip Code:72360-8529
Mailing Address - Country:US
Mailing Address - Phone:870-295-3557
Mailing Address - Fax:870-295-3686
Practice Address - Street 1:1679 HIGHWAY 243 S
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:AR
Practice Address - Zip Code:72360-8529
Practice Address - Country:US
Practice Address - Phone:870-295-3557
Practice Address - Fax:870-295-3686
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-05
Last Update Date:2019-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No177F00000XOther Service ProvidersLodging
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR121812732Medicaid