Provider Demographics
NPI:1891179560
Name:RANDOLPH SNF OPERATIONS LLC
Entity Type:Organization
Organization Name:RANDOLPH SNF OPERATIONS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ROSS
Authorized Official - Middle Name:
Authorized Official - Last Name:PONTHIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-443-8167
Mailing Address - Street 1:105 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:POCAHONTAS
Mailing Address - State:AR
Mailing Address - Zip Code:72455-1364
Mailing Address - Country:US
Mailing Address - Phone:870-892-2523
Mailing Address - Fax:870-892-1469
Practice Address - Street 1:105 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:POCAHONTAS
Practice Address - State:AR
Practice Address - Zip Code:72455-1364
Practice Address - Country:US
Practice Address - Phone:870-892-2523
Practice Address - Fax:870-892-1469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-13
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
045284Medicare Oscar/Certification