Provider Demographics
NPI:1245526813
Name:SOUTHRIDGE VILLAGE-CABOT MGNT. CO.
Entity type:Organization
Organization Name:SOUTHRIDGE VILLAGE-CABOT MGNT. CO.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GRETCHEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:HUMPHREYS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-362-7023
Mailing Address - Street 1:401 SOUTHRIDGE PKWY
Mailing Address - Street 2:
Mailing Address - City:HEBER SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72543-8853
Mailing Address - Country:US
Mailing Address - Phone:501-362-7023
Mailing Address - Fax:501-362-5214
Practice Address - Street 1:601 E. MT. SPRINGS ROAD
Practice Address - Street 2:
Practice Address - City:CABOT
Practice Address - State:AR
Practice Address - Zip Code:72023
Practice Address - Country:US
Practice Address - Phone:501-286-7720
Practice Address - Fax:501-286-7721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-22
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR057310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR057OtherARKANSAS DEPARTMENT OF HUMAN SERVICES