Healthcare Provider Details

I. General information

NPI: 1962805812
Provider Name (Legal Business Name): ALLOPLASTIC RECONSTRUCTION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2014
Last Update Date: 01/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 W GE PATTERSON AVE SUITE 102
MEMPHIS TN
38103-6413
US

IV. Provider business mailing address

220 N. VAN BUREN
LITTLE ROCK AR
72205
US

V. Phone/Fax

Practice location:
  • Phone: 901-410-5375
  • Fax: 800-977-4149
Mailing address:
  • Phone: 501-265-0100
  • Fax: 800-977-4149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code156FX1700X
TaxonomyOcularist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License NumberOPP00038
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code229N00000X
TaxonomyAnaplastologist
License Number
License Number State

VIII. Authorized Official

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