1790124659 NPI number — KIDSCORP OF FAYETTEVILLE, INC

Table of content: (NPI 1790124659)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790124659 NPI number — KIDSCORP OF FAYETTEVILLE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIDSCORP OF FAYETTEVILLE, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790124659
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/25/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 130
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROGERS
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72757-0130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-856-6397
Provider Business Mailing Address Fax Number:
479-856-6412

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2210 MAIN DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGDALE
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72762-6802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-856-6397
Provider Business Practice Location Address Fax Number:
479-856-6412
Provider Enumeration Date:
06/24/2013

Additional Information

Authorized Official

Authorized Official Last Name:
WILKERSON
Authorized Official First Name:
SHELIA
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
CLINICAL DIRECTOR
Authorized Official Telephone Number:
479-986-5150

Provider Taxonomy Codes

  • Taxonomy code: 261QD1600X , with the licence number:  28786 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 198277724 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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