=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215218060
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCING LIFE SKILLS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2011
-----------------------------------------------------
Last Update Date | 10/14/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1218 STONE ST. SUITE 110
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-275-6035
-----------------------------------------------------
Fax | 870-275-6249
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1218 STONE ST. SUITE 110
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-275-6035
-----------------------------------------------------
Fax | 870-275-6249
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. WILLIAM CLAY WOLTERS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 870-275-6035
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------