Provider Demographics
NPI:1922582477
Name:WATERS OF FORT SMITH LLC
Entity Type:Organization
Organization Name:WATERS OF FORT SMITH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MOISHE
Authorized Official - Middle Name:
Authorized Official - Last Name:GUBIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-449-1900
Mailing Address - Street 1:5301 WHEELER AVE
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72901-8339
Mailing Address - Country:US
Mailing Address - Phone:479-646-3454
Mailing Address - Fax:
Practice Address - Street 1:5301 WHEELER AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-8339
Practice Address - Country:US
Practice Address - Phone:479-646-3454
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-20
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility