Healthcare Provider Details

I. General information

NPI: 1487340535
Provider Name (Legal Business Name): KID CHAMPION HOLDING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2023
Last Update Date: 04/12/2023
Certification Date: 04/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11400 N RODNEY PARHAM RD STE C
LITTLE ROCK AR
72212-4124
US

IV. Provider business mailing address

11400 N RODNEY PARHAM RD STE C
LITTLE ROCK AR
72212-4124
US

V. Phone/Fax

Practice location:
  • Phone: 501-954-0667
  • Fax:
Mailing address:
  • Phone: 501-804-9298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: KEVIN LEE KELLEY
Title or Position: MANAGER / CEO
Credential:
Phone: 501-804-9298