Provider Demographics
NPI:1427444124
Name:HOLIDAY ISLAND OPERATIONS, LLC
Entity type:Organization
Organization Name:HOLIDAY ISLAND OPERATIONS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:DENNINGTON
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-530-3779
Mailing Address - Street 1:89 HILLSIDE DRIVE
Mailing Address - Street 2:
Mailing Address - City:HOLIDAY ISLAND
Mailing Address - State:AR
Mailing Address - Zip Code:72631
Mailing Address - Country:US
Mailing Address - Phone:479-253-6553
Mailing Address - Fax:479-253-5043
Practice Address - Street 1:89 HILLSIDE DRIVE
Practice Address - Street 2:
Practice Address - City:HOLIDAY ISLAND
Practice Address - State:AR
Practice Address - Zip Code:72631
Practice Address - Country:US
Practice Address - Phone:479-253-6553
Practice Address - Fax:479-253-5043
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-09
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR105310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR206460794Medicaid