Healthcare Provider Details

I. General information

NPI: 1073914719
Provider Name (Legal Business Name): EVGUENI ROUDACHEVSKI, D.O.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2014
Last Update Date: 09/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11912 KANIS RD STE F2
LITTLE ROCK AR
72211-3771
US

IV. Provider business mailing address

11912 KANIS RD STE F2
LITTLE ROCK AR
72211-3771
US

V. Phone/Fax

Practice location:
  • Phone: 501-227-8020
  • Fax: 501-227-8826
Mailing address:
  • Phone: 501-227-8020
  • Fax: 501-227-8826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberA03199
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberA03199
License Number StateAR

VIII. Authorized Official

Name: MRS. HAPSY GLOVER
Title or Position: APN
Credential: APN
Phone: 501-227-8020