Healthcare Provider Details

I. General information

NPI: 1720751373
Provider Name (Legal Business Name): OUR BROTHER'S KEEPER WELLNESS ORGANIZATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2021
Last Update Date: 07/29/2021
Certification Date: 07/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7101 W 12TH ST STE 200I
LITTLE ROCK AR
72204-2404
US

IV. Provider business mailing address

PO BOX 46346
LITTLE ROCK AR
72214-6346
US

V. Phone/Fax

Practice location:
  • Phone: 501-647-1042
  • Fax:
Mailing address:
  • Phone: 501-647-1042
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: TANYA MARYIE BELL-BROOKS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 501-412-2268