Provider Demographics
NPI:1780633222
Name:INDIAN ROCK VILLAGE, LLC
Entity Type:Organization
Organization Name:INDIAN ROCK VILLAGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:VICTOR
Authorized Official - Last Name:HOLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-224-0846
Mailing Address - Street 1:265 DAVE CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD BAY
Mailing Address - State:AR
Mailing Address - Zip Code:72088-3106
Mailing Address - Country:US
Mailing Address - Phone:501-884-3210
Mailing Address - Fax:501-884-6800
Practice Address - Street 1:265 DAVE CREEK PARKWAY
Practice Address - Street 2:
Practice Address - City:FAIRFIELD BAY
Practice Address - State:AR
Practice Address - Zip Code:72088-3136
Practice Address - Country:US
Practice Address - Phone:501-884-3210
Practice Address - Fax:501-884-6800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2013-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR452313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR045153Medicare ID - Type Unspecified