Provider Demographics
NPI:1679837314
Name:LITTLE ROCK ENRICHMENT CENTER, INC.
Entity type:Organization
Organization Name:LITTLE ROCK ENRICHMENT CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ DIRECTOR/ OWNER/ MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DARIC
Authorized Official - Middle Name:LAMONT
Authorized Official - Last Name:WASHINGTON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:501-310-1150
Mailing Address - Street 1:13003 STACY LN
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-3238
Mailing Address - Country:US
Mailing Address - Phone:501-310-1150
Mailing Address - Fax:501-353-0806
Practice Address - Street 1:13003 STACY LN
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72211-3238
Practice Address - Country:US
Practice Address - Phone:501-310-1150
Practice Address - Fax:501-353-0806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-27
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR149310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR188968755Medicaid
AR188967756Medicaid
AR192059757Medicaid