Healthcare Provider Details

I. General information

NPI: 1821085499
Provider Name (Legal Business Name): ACC 1, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 03/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6301 S HAZEL ST
PINE BLUFF AR
71603-7818
US

IV. Provider business mailing address

6301 S HAZEL ST
PINE BLUFF AR
71603-7818
US

V. Phone/Fax

Practice location:
  • Phone: 870-534-8153
  • Fax: 870-534-6073
Mailing address:
  • Phone: 870-534-8153
  • Fax: 870-534-6073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. KYLE MARK DESHOTELS
Title or Position: MANAGING/MEMBER
Credential:
Phone: 870-733-1255