Healthcare Provider Details

I. General information

NPI: 1265955512
Provider Name (Legal Business Name): KIDS EL MELBOURNE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2017
Last Update Date: 07/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

889 EAST MAIN
MELBOURNE AR
72556
US

IV. Provider business mailing address

PO BOX 967
MELBOURNE AR
72556
US

V. Phone/Fax

Practice location:
  • Phone: 870-368-4586
  • Fax: 870-368-4587
Mailing address:
  • Phone: 870-368-4586
  • Fax: 870-368-4587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License Number
License Number State

VIII. Authorized Official

Name: DEBBIE COLEMAN
Title or Position: OWNER
Credential:
Phone: 870-368-4586