Provider Demographics
NPI:1740236777
Name:NORTHPORT HEALTH SERVICES OF ARKANSAS, LLC
Entity Type:Organization
Organization Name:NORTHPORT HEALTH SERVICES OF ARKANSAS, LLC
Other - Org Name:LEGACY HEALTH & REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:CODY
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-391-3600
Mailing Address - Street 1:3310 N 50TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72904-4451
Mailing Address - Country:US
Mailing Address - Phone:479-783-3101
Mailing Address - Fax:
Practice Address - Street 1:3310 N 50TH ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72904-4451
Practice Address - Country:US
Practice Address - Phone:479-783-3101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR593314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR119591311Medicaid
AR119591311Medicaid