Provider Demographics
NPI:1154762987
Name:FIRSTLIGHT HOME CARE NWA
Entity type:Organization
Organization Name:FIRSTLIGHT HOME CARE NWA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-899-6955
Mailing Address - Street 1:1400 W WALNUT ST
Mailing Address - Street 2:SUITE #106
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-3339
Mailing Address - Country:US
Mailing Address - Phone:479-899-6955
Mailing Address - Fax:479-270-1612
Practice Address - Street 1:1400 W WALNUT ST
Practice Address - Street 2:SUITE #106
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-3339
Practice Address - Country:US
Practice Address - Phone:479-899-6955
Practice Address - Fax:479-270-1612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-09
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care