Provider Demographics
NPI:1699764951
Name:MINE CREEK HEALTHCARE CENTER, LLC
Entity type:Organization
Organization Name:MINE CREEK HEALTHCARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:JEANES
Authorized Official - Suffix:
Authorized Official - Credentials:ADMINISTRATOR
Authorized Official - Phone:870-845-2021
Mailing Address - Street 1:PO BOX 812
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:71852-0812
Mailing Address - Country:US
Mailing Address - Phone:870-845-2021
Mailing Address - Fax:870-845-5412
Practice Address - Street 1:1407 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:AR
Practice Address - Zip Code:71852-3733
Practice Address - Country:US
Practice Address - Phone:870-845-2021
Practice Address - Fax:870-845-5412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-19
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR207QG0300X314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR045180Medicare Oscar/Certification