Provider Demographics
NPI:1194897355
Name:CONCORDIA QUILT, LLC
Entity type:Organization
Organization Name:CONCORDIA QUILT, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:WITT
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:505-797-8735
Mailing Address - Street 1:7 PROFESSIONAL DR
Mailing Address - Street 2:
Mailing Address - City:BELLA VISTA
Mailing Address - State:AR
Mailing Address - Zip Code:72714-2462
Mailing Address - Country:US
Mailing Address - Phone:479-855-3735
Mailing Address - Fax:479-855-4697
Practice Address - Street 1:7 PROFESSIONAL DR
Practice Address - Street 2:
Practice Address - City:BELLA VISTA
Practice Address - State:AR
Practice Address - Zip Code:72714-2462
Practice Address - Country:US
Practice Address - Phone:479-855-3735
Practice Address - Fax:479-855-4697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR376314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARV564P-1054OtherVA PROVIDER NUMBER
ARV564P-1054OtherVA PROVIDER NUMBER