Healthcare Provider Details

I. General information

NPI: 1114109147
Provider Name (Legal Business Name): MR. RONALD KIRBY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2007
Last Update Date: 12/13/2021
Certification Date: 12/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6210 BASELINE ROAD THE P.A.T. CENTER
LITTLE ROCK AR
72209
US

IV. Provider business mailing address

6210 BASELINE RD
LITTLE ROCK AR
72209
US

V. Phone/Fax

Practice location:
  • Phone: 501-265-0302
  • Fax: 501-265-0300
Mailing address:
  • Phone: 501-412-8861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: