Provider Demographics
NPI:1245310440
Name:INNISFREE NURSING & REHABILITATION, LLC
Entity type:Organization
Organization Name:INNISFREE NURSING & REHABILITATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:B
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-636-5545
Mailing Address - Street 1:301 S 24TH ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-1116
Mailing Address - Country:US
Mailing Address - Phone:479-636-5545
Mailing Address - Fax:479-621-9095
Practice Address - Street 1:301 S 24TH ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-1116
Practice Address - Country:US
Practice Address - Phone:479-636-5545
Practice Address - Fax:479-621-9095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR552314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR015302OtherMEDIPAK PROVIDER NUMBER
AR045302Medicare ID - Type Unspecified