Provider Demographics
NPI:1194349241
Name:STALEY HOUSE LLC
Entity type:Organization
Organization Name:STALEY HOUSE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MISTI
Authorized Official - Middle Name:
Authorized Official - Last Name:STALEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-490-9973
Mailing Address - Street 1:804 COLUMBIA
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:AR
Mailing Address - Zip Code:72342-2816
Mailing Address - Country:US
Mailing Address - Phone:770-490-9973
Mailing Address - Fax:
Practice Address - Street 1:804 COLUMBIA
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:AR
Practice Address - Zip Code:72342-2816
Practice Address - Country:US
Practice Address - Phone:770-490-9973
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-04
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition