=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003448309
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPECTRUM LIVING SOLUTIONS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2020
-----------------------------------------------------
Last Update Date | 02/05/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3677 W WEIR RD
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72704-5906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-871-2481
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4375 N VANTAGE DR STE 104
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72703-4986
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-717-7546
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BOARD CHAIRMAN
-----------------------------------------------------
Name | ASHTON P MCCOMBS III
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 630-248-8892
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------