Provider Demographics
NPI:1174514616
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 1:610 S AVALON ST
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-4109
Mailing Address - Country:US
Mailing Address - Phone:870-735-4543
Mailing Address - Fax:
Practice Address - Street 1:610 S AVALON ST
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-4109
Practice Address - Country:US
Practice Address - Phone:870-735-4543
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
AR374314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
045217Medicare Oscar/Certification
AR0356800002Medicare NSC