Provider Demographics
NPI:1649343195
Name:LAWRENCE HALL HEALTH & REHABILITATION
Entity type:Organization
Organization Name:LAWRENCE HALL HEALTH & REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:K
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-886-1263
Mailing Address - Street 1:PO BOX 839
Mailing Address - Street 2:
Mailing Address - City:WALNUT RIDGE
Mailing Address - State:AR
Mailing Address - Zip Code:72476-0839
Mailing Address - Country:US
Mailing Address - Phone:870-886-1295
Mailing Address - Fax:870-886-6099
Practice Address - Street 1:1051 W FREE ST
Practice Address - Street 2:
Practice Address - City:WALNUT RIDGE
Practice Address - State:AR
Practice Address - Zip Code:72476-1753
Practice Address - Country:US
Practice Address - Phone:870-886-1295
Practice Address - Fax:870-886-6099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR196313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR119707311Medicaid
AR318937Medicare PIN
AR04-5452Medicare PIN