1699957928 NPI number — ALLOPLASTIC FACIAL RECONSTRUCTION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699957928 NPI number — ALLOPLASTIC FACIAL RECONSTRUCTION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALLOPLASTIC FACIAL RECONSTRUCTION
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:
ALLOPLASTIC RECONSTRUCTION INC
Provider Other Organization Name Type Code:
3
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:
1699957928
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3924 W MARKHAM ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72205-5528
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-265-0100
Provider Business Mailing Address Fax Number:
501-265-0102

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3924 W MARKHAM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72205-5528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-265-0100
Provider Business Practice Location Address Fax Number:
501-265-0102
Provider Enumeration Date:
11/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KACZKOWSKI
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
D
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
501-265-0100

Provider Taxonomy Codes

  • Taxonomy code: 332BC3200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 02593066 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 140207716 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 49597 . This is a "BCBS" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".




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