Provider Demographics
NPI:1720512643
Name:JACKSONVILLE CARE CENTER, LLC
Entity Type:Organization
Organization Name:JACKSONVILLE CARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:SAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-783-4672
Mailing Address - Street 1:415 ROGERS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72901-1903
Mailing Address - Country:US
Mailing Address - Phone:479-783-4672
Mailing Address - Fax:479-783-2217
Practice Address - Street 1:1500 GRAHAM RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-3837
Practice Address - Country:US
Practice Address - Phone:501-982-5545
Practice Address - Fax:501-982-0016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-18
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR502310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility