Provider Demographics
NPI:1649051665
Name:MIRA AT MAUMELLE
Entity type:Organization
Organization Name:MIRA AT MAUMELLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:MBR
Authorized Official - Phone:320-492-5483
Mailing Address - Street 1:925 COUNTRY CLUB PARKWAY
Mailing Address - Street 2:
Mailing Address - City:MAUMELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72113
Mailing Address - Country:US
Mailing Address - Phone:952-254-1362
Mailing Address - Fax:
Practice Address - Street 1:925 COUNTRY CLUB PARKWAY, MAUMELLE, AR, USA
Practice Address - Street 2:
Practice Address - City:MAUMELLE
Practice Address - State:AR
Practice Address - Zip Code:72113
Practice Address - Country:US
Practice Address - Phone:952-254-1362
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIRA AT MAUMELLE , LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-10-06
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility