Provider Demographics
NPI:1851443022
Name:WASHINGTON REGIONAL MEDICORP, INC.
Entity Type:Organization
Organization Name:WASHINGTON REGIONAL MEDICORP, INC.
Other - Org Name:FAYETTEVILLE CITY HOSPITAL AND GERIATRIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JANE
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:LEDBETTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-442-5100
Mailing Address - Street 1:221 S SCHOOL AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72701-5969
Mailing Address - Country:US
Mailing Address - Phone:479-442-5100
Mailing Address - Fax:479-587-2679
Practice Address - Street 1:221 S SCHOOL AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-5969
Practice Address - Country:US
Practice Address - Phone:479-442-5100
Practice Address - Fax:479-587-2679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR487314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR04-5169Medicare Oscar/Certification