Provider Demographics
NPI:1548251077
Name:WAVERLEY - ARKANSAS, INC.
Entity type:Organization
Organization Name:WAVERLEY - ARKANSAS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY / TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHAUNCEY
Authorized Official - Middle Name:R
Authorized Official - Last Name:DUNBAR
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:601-956-1576
Mailing Address - Street 1:100 9TH ST
Mailing Address - Street 2:
Mailing Address - City:MENA
Mailing Address - State:AR
Mailing Address - Zip Code:71953-3026
Mailing Address - Country:US
Mailing Address - Phone:479-394-2617
Mailing Address - Fax:
Practice Address - Street 1:100 9TH ST
Practice Address - Street 2:
Practice Address - City:MENA
Practice Address - State:AR
Practice Address - Zip Code:71953-3026
Practice Address - Country:US
Practice Address - Phone:479-394-2617
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAVERLEY-ARKANSAS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-03
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR373314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
045229Medicare Oscar/Certification
AR0356800001Medicare NSC