Basic Information
Provider Information | |||||||||
NPI: | 1174968747 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BIRCH TREE COMMUNITIES, INC - NEW BEGINNINGS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BIRCH TREE COMMUNITIES, INC. | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1589 | ||||||||
Address2: |   | ||||||||
City: | BENTON | ||||||||
State: | AR | ||||||||
PostalCode: | 720181589 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5013153344 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 718 ALCOA RD | ||||||||
Address2: |   | ||||||||
City: | BENTON | ||||||||
State: | AR | ||||||||
PostalCode: | 720153406 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5013153344 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/08/2013 | ||||||||
LastUpdateDate: | 05/08/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GARCIA | ||||||||
AuthorizedOfficialFirstName: | ROLANDO | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 5013153344 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | BIRCH TREE COMMUNITIES, INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CFO | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   | AR | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 132674786 | 05 | AR |   | MEDICAID | 116374726 | 05 | AR |   | MEDICAID |