Basic Information
| Provider Information | |||||||||
| NPI: | 1770873499 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BIRCH TREE COMMUNITIES, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CLARKSVILLE BRANCH - PHOENIX CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1589 | ||||||||
| Address2: | |||||||||
| City: | BENTON | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013153344 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 706 N BROWN ST | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 728302732 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797051301 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2011 | ||||||||
| LastUpdateDate: | 04/14/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GARCIA | ||||||||
| AuthorizedOfficialFirstName: | ROLANDO | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5013153344 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| 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 | 116374726 | 05 | AR | MEDICAID |