Basic Information
| Provider Information | |||||||||
| NPI: | 1053464826 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BUTTERFIELD TRAIL VILLAGE, INC. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1923 E JOYCE BLVD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727035205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794427220 | ||||||||
| FaxNumber: | 4794422019 | ||||||||
| Practice Location | |||||||||
| Address1: | 1923 E JOYCE BLVD | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727035205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4794427220 | ||||||||
| FaxNumber: | 4794422019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | WICKIZER | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4794427220 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 365 | AR | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.