Healthcare Provider Details

I. General information

NPI: 1598049744
Provider Name (Legal Business Name): ALLOPLASTIC RECONSTRUCTION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2011
Last Update Date: 09/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3924 W MARKHAM ST
LITTLE ROCK AR
72205-5528
US

IV. Provider business mailing address

3924 W MARKHAM ST
LITTLE ROCK AR
72205-5528
US

V. Phone/Fax

Practice location:
  • Phone: 501-265-0100
  • Fax: 501-265-0102
Mailing address:
  • Phone: 501-265-0100
  • Fax: 501-265-0102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code229N00000X
TaxonomyAnaplastologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberOPP00038
License Number StateAR
# 5
Primary TaxonomyY
Taxonomy Code156FX1700X
TaxonomyOcularist
License Number
License Number State

VIII. Authorized Official

Name: MR. MICHAEL KACZKOWSKI
Title or Position: PRESIDENT
Credential:
Phone: 501-265-0100