Healthcare Provider Details

I. General information

NPI: 1306591201
Provider Name (Legal Business Name): KIDS FOR THE FUTURE OF WESTERN BENTON COUNTY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2022
Last Update Date: 02/18/2022
Certification Date: 02/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 S MAIN ST
DECATUR AR
72722-9799
US

IV. Provider business mailing address

PO BOX 130
ROGERS AR
72757-0130
US

V. Phone/Fax

Practice location:
  • Phone: 479-212-5030
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD1600X
TaxonomyDevelopmental Disabilities Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SHELIA WILKERSON
Title or Position: DIRECTOR
Credential:
Phone: 479-986-5150