Provider Demographics
NPI:1992979504
Name:SILOAM SPRINGS ADULT DEVELOPMENT INC
Entity type:Organization
Organization Name:SILOAM SPRINGS ADULT DEVELOPMENT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:G
Authorized Official - Last Name:DEZURIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-524-5911
Mailing Address - Street 1:PO BOX 585
Mailing Address - Street 2:
Mailing Address - City:SILOAM SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72761-0585
Mailing Address - Country:US
Mailing Address - Phone:479-524-5911
Mailing Address - Fax:479-524-8075
Practice Address - Street 1:500 N COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:SILOAM SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:72761-2920
Practice Address - Country:US
Practice Address - Phone:479-524-5911
Practice Address - Fax:479-524-8075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR251C00000X251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services