Basic Information
| Provider Information | |||||||||
| NPI: | 1598710808 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHPORT HEALTH SERVICES OF ARKANSAS, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COVINGTON COURT HEALTH & REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4500 OLD GREENWOOD RD | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729036417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4796465700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4500 OLD GREENWOOD RD | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729036417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4796465700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2006 | ||||||||
| LastUpdateDate: | 10/26/2020 | ||||||||
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| AuthorizedOfficialLastName: | LONG | ||||||||
| AuthorizedOfficialFirstName: | PHILLIP | ||||||||
| AuthorizedOfficialMiddleName: | CODY | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2053913600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 591 | AR | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 119660311 | 05 | AR | MEDICAID |