=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306057906
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BABYBOOMERS ADULT DAYCARE CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2007
-----------------------------------------------------
Last Update Date | 09/24/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3105 W 12TH ST
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72204-2224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-614-7999
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3105 W 12TH ST
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72204-2224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-614-7999
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MRS. SHARON D CAMPBELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 501-614-7999
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311500000X
-----------------------------------------------------
Taxonomy Name | Alzheimer Center (Dementia Center)
-----------------------------------------------------
License Number | 0098
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------