Healthcare Provider Details

I. General information

NPI: 1811536253
Provider Name (Legal Business Name): KIKI DANCE STUDIO & WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2020
Last Update Date: 02/23/2020
Certification Date: 02/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 S GEE ST STE A
JONESBORO AR
72401-3308
US

IV. Provider business mailing address

721 S GEE ST STE A
JONESBORO AR
72401-3308
US

V. Phone/Fax

Practice location:
  • Phone: 870-882-1725
  • Fax:
Mailing address:
  • Phone: 870-882-1725
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name: KYJIONE KING
Title or Position: OWNER
Credential:
Phone: 870-882-8345