Provider Demographics
NPI:1154541878
Name:ST JOHN'S PLACE OF ARKANSAS, LLC
Entity type:Organization
Organization Name:ST JOHN'S PLACE OF ARKANSAS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:PONTHIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-216-3316
Mailing Address - Street 1:1400 HIGHWAY 79 167 BYP
Mailing Address - Street 2:
Mailing Address - City:FORDYCE
Mailing Address - State:AR
Mailing Address - Zip Code:71742-1728
Mailing Address - Country:US
Mailing Address - Phone:870-352-2104
Mailing Address - Fax:870-352-8969
Practice Address - Street 1:1400 HIGHWAY 79 167 BYP
Practice Address - Street 2:
Practice Address - City:FORDYCE
Practice Address - State:AR
Practice Address - Zip Code:71742-1728
Practice Address - Country:US
Practice Address - Phone:870-352-2104
Practice Address - Fax:870-352-8969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR832314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR162887311Medicaid