Provider Demographics
NPI:1740498450
Name:VILLAGE PARK RESIDENTIAL LIVING INC
Entity type:Organization
Organization Name:VILLAGE PARK RESIDENTIAL LIVING INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KAYE
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-327-6428
Mailing Address - Street 1:1622 SCOTT ST
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034-5235
Mailing Address - Country:US
Mailing Address - Phone:501-327-6428
Mailing Address - Fax:
Practice Address - Street 1:1622 SCOTT ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034-5235
Practice Address - Country:US
Practice Address - Phone:501-327-6428
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR470 RCF310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility