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General NPI Number Information
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NPI Number | 1235413485
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Entity Type | Organization
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Legal Business Name | REAL LIFE SKIN
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Dates
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Enumeration Date | 10/06/2011
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Last Update Date | 10/06/2011
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Provider Practice Location Address
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Address Line | 220 N VAN BUREN ST
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City | LITTLE ROCK
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State | AR
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Zip | 72205-3650
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Country | US
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Telephone | 501-265-0100
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Fax | 501-265-0102
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Provider Business Mailing Address
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Address Line | P O BOX 56182
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City | LITTLE ROCK
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State | AR
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Zip | 72215-6182
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Country | US
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Telephone | 501-265-0100
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Fax | 501-265-0102
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. MICHAEL KACZKOWSKI
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Credential |
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Telephone | 501-265-0100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332BC3200X
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Taxonomy Name | Customized Equipment (DME)
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License Number |
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License Number State |
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