Healthcare Provider Details

I. General information

NPI: 1013139401
Provider Name (Legal Business Name): KIDZ KAN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 05/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 HIGHWAY 64 WEST
BEEBE AR
72012-2094
US

IV. Provider business mailing address

130 UNDERHILL RD
BEEBE AR
72012-9751
US

V. Phone/Fax

Practice location:
  • Phone: 501-230-3100
  • Fax: 501-882-9825
Mailing address:
  • Phone: 501-230-3100
  • Fax: 501-882-2801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MRS. KELLEY D LEWIS
Title or Position: ADMINISTRATOR
Credential: OTRL
Phone: 501-230-3100