Healthcare Provider Details

I. General information

NPI: 1699957928
Provider Name (Legal Business Name): ALLOPLASTIC FACIAL RECONSTRUCTION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2007
Last Update Date: 10/02/2020
Certification Date: 10/02/2020
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 TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

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