Healthcare Provider Details

I. General information

NPI: 1306101142
Provider Name (Legal Business Name): KASANDRA SHACKELFORD RECOVERY ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2012
Last Update Date: 03/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 W SOUTH ST
BENTON AR
72015-3776
US

IV. Provider business mailing address

109 W SOUTH ST
BENTON AR
72015-3776
US

V. Phone/Fax

Practice location:
  • Phone: 501-776-1191
  • Fax: 501-776-1194
Mailing address:
  • Phone: 501-776-1191
  • Fax: 501-776-1194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: