Provider Demographics
NPI:1801445267
Name:BLACKMON CARE HOME CARE
Entity type:Organization
Organization Name:BLACKMON CARE HOME CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LONZELL
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKMON
Authorized Official - Suffix:
Authorized Official - Credentials:OWNER
Authorized Official - Phone:501-256-6203
Mailing Address - Street 1:PO BOX 1383
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72203-1383
Mailing Address - Country:US
Mailing Address - Phone:501-256-6293
Mailing Address - Fax:
Practice Address - Street 1:10 ROXBURY DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72209-2133
Practice Address - Country:US
Practice Address - Phone:501-256-6203
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-09
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR233644797Medicaid
AR233639732Medicaid