Provider Demographics
NPI:1679890511
Name:STAP, INC.
Entity Type:Organization
Organization Name:STAP, INC.
Other - Org Name:ST. ANDREWS PLACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:JUNE
Authorized Official - Last Name:KILGORE
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:479-474-6885
Mailing Address - Street 1:2010 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-4957
Mailing Address - Country:US
Mailing Address - Phone:479-474-6885
Mailing Address - Fax:479-474-9523
Practice Address - Street 1:3501 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-7281
Practice Address - Country:US
Practice Address - Phone:501-329-9879
Practice Address - Fax:501-329-6673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-03
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR181708311Medicaid
AR045313Medicare Oscar/Certification