=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144169079
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BEHAVIORAL HEALTH SERVICES OF WEST MEMPHIS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2026
-----------------------------------------------------
Last Update Date | 03/26/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 410 S AVALON ST
-----------------------------------------------------
City | WEST MEMPHIS
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72301-4183
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-461-3791
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2925 10TH AVE N
-----------------------------------------------------
City | PALM SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33461-3000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | KIRILL VESSELOV
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 561-461-3791
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 283Q00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Hospital
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------