Provider Demographics
NPI:1215444963
Name:SOULS HARBOR OF ROGERS INC.
Entity type:Organization
Organization Name:SOULS HARBOR OF ROGERS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:FIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-640-4225
Mailing Address - Street 1:1206 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72756-2836
Mailing Address - Country:US
Mailing Address - Phone:479-640-4225
Mailing Address - Fax:
Practice Address - Street 1:1206 N 2ND ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756-2836
Practice Address - Country:US
Practice Address - Phone:479-640-4225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-03
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR261QM0850X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health