Provider Demographics
NPI:1851440309
Name:STONERIDGE HEALTH AND REHAB CENTER
Entity Type:Organization
Organization Name:STONERIDGE HEALTH AND REHAB CENTER
Other - Org Name:STONERIDGE HEALTH & REHAB CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KURT
Authorized Official - Middle Name:L
Authorized Official - Last Name:LUTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-833-5627
Mailing Address - Street 1:1051 LANTRIP RD
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72120-4161
Mailing Address - Country:US
Mailing Address - Phone:501-833-5627
Mailing Address - Fax:501-835-6905
Practice Address - Street 1:4017 FRANKLIN
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:AR
Practice Address - Zip Code:72053
Practice Address - Country:US
Practice Address - Phone:501-490-1533
Practice Address - Fax:501-490-0608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2014-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR0798313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR162852311Medicaid
AR162852311Medicaid