Provider Demographics
NPI:1336228394
Name:MEDICALODGES, INC.
Entity Type:Organization
Organization Name:MEDICALODGES, INC.
Other - Org Name:GRAN VILLAS TEXARKANA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:W
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-251-6700
Mailing Address - Street 1:1625 E 42ND ST
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:AR
Mailing Address - Zip Code:71854-1654
Mailing Address - Country:US
Mailing Address - Phone:870-772-0689
Mailing Address - Fax:870-772-1103
Practice Address - Street 1:1625 E 42ND ST
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:AR
Practice Address - Zip Code:71854-1654
Practice Address - Country:US
Practice Address - Phone:870-772-0689
Practice Address - Fax:870-772-1103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR427251E00000X, 261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR427Medicaid