Basic Information
| Provider Information | |||||||||
| NPI: | 1134678337 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BIRCH TREE COMMUNITIES, INC. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1589 | ||||||||
| Address2: | |||||||||
| City: | BENTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720181589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013153344 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1718 OLD HOT SPRINGS HIGHWAY | ||||||||
| Address2: | |||||||||
| City: | BENTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013153344 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2016 | ||||||||
| LastUpdateDate: | 09/28/2016 | ||||||||
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| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | PEYTON | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | RECOVERY ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 5013153344 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | AR | Y | Agencies | Case Management |
ID Information
| ID | Type | State | Issuer | Description | 1538102223 | 05 | AR | MEDICAID |