Provider Demographics
NPI:1104814383
Name:HAZEL STREET NURSING ASSOCIATION
Entity type:Organization
Organization Name:HAZEL STREET NURSING ASSOCIATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:SHEPARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-541-0342
Mailing Address - Street 1:6811 S HAZEL ST
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-7829
Mailing Address - Country:US
Mailing Address - Phone:870-535-1155
Mailing Address - Fax:870-535-0732
Practice Address - Street 1:6811 S HAZEL ST
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-7829
Practice Address - Country:US
Practice Address - Phone:870-535-1155
Practice Address - Fax:870-535-0732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR725314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR119733311Medicaid
AR119733311Medicaid