Provider Demographics
NPI:1063919892
Name:THESE OLD BONEZ ENTERPRISES
Entity type:Organization
Organization Name:THESE OLD BONEZ ENTERPRISES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHERESE
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:187-051-4938
Mailing Address - Street 1:PO BOX 1298
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72303-1298
Mailing Address - Country:US
Mailing Address - Phone:870-514-9383
Mailing Address - Fax:
Practice Address - Street 1:2144 HWY147 SOUTH- BUILDING A
Practice Address - Street 2:
Practice Address - City:PROCTOR
Practice Address - State:AR
Practice Address - Zip Code:72376-2346
Practice Address - Country:US
Practice Address - Phone:870-277-0082
Practice Address - Fax:901-205-0597
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THESE OLD BONEZ ENTERPRISES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-04-09
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251300000X, 251B00000X, 251J00000X, 251T00000X, 253Z00000X, 261QM0801X, 320800000X, 320900000X, 343900000X, 347C00000X, 385H00000X, 3747P1801X
AR251E00000X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
No251300000XAgenciesLocal Education Agency (LEA)
No251B00000XAgenciesCase Management
No251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care
No251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization
No253Z00000XAgenciesIn Home Supportive Care
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental DisabilitiesGroup - Multi-Specialty
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347C00000XTransportation ServicesPrivate Vehicle
No385H00000XRespite Care FacilityRespite CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR229140797Medicaid
AR33859OtherDHS
AR1063919892Medicaid
AR232529732Medicaid