Provider Demographics
NPI:1386732030
Name:PINE RIDGE HEALTHCARE, LLC
Entity type:Organization
Organization Name:PINE RIDGE HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AGENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICK
Authorized Official - Middle Name:D
Authorized Official - Last Name:SAMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-523-4333
Mailing Address - Street 1:1005 MCLAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:AR
Mailing Address - Zip Code:72112-3529
Mailing Address - Country:US
Mailing Address - Phone:870-523-4333
Mailing Address - Fax:870-523-4341
Practice Address - Street 1:1501 S BAY ST
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-3040
Practice Address - Country:US
Practice Address - Phone:870-535-8878
Practice Address - Fax:870-535-0640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR801314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility