Healthcare Provider Details

I. General information

NPI: 1609997311
Provider Name (Legal Business Name): KID SUCCESS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 06/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2740 COLLEGE AVENUE
CONWAY AR
72034
US

IV. Provider business mailing address

2740 COLLEGE AVENUE
CONWAY AR
72034
US

V. Phone/Fax

Practice location:
  • Phone: 501-328-5696
  • Fax: 501-328-5020
Mailing address:
  • Phone: 501-328-5696
  • Fax: 501-328-5020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AMANDA DENTON
Title or Position: OWNER
Credential: PT
Phone: 501-329-5459