Healthcare Provider Details

I. General information

NPI: 1235413485
Provider Name (Legal Business Name): REAL LIFE SKIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

220 N VAN BUREN ST
LITTLE ROCK AR
72205-3650
US

IV. Provider business mailing address

P O BOX 56182
LITTLE ROCK AR
72215-6182
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 TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

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