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General NPI Number Information
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NPI Number | 1487340535
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Entity Type | Organization
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Legal Business Name | KID CHAMPION HOLDING LLC
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Dates
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Enumeration Date | 04/12/2023
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Last Update Date | 04/12/2023
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Provider Practice Location Address
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Address Line | 11400 N RODNEY PARHAM RD STE C
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City | LITTLE ROCK
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State | AR
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Zip | 72212-4124
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Country | US
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Telephone | 501-954-0667
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Fax |
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Provider Business Mailing Address
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Address Line | 11400 N RODNEY PARHAM RD STE C
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City | LITTLE ROCK
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State | AR
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Zip | 72212-4124
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Country | US
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Telephone | 501-804-9298
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Fax |
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Authorized Official
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Title or Position | MANAGER / CEO
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Name | KEVIN LEE KELLEY
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Credential |
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Telephone | 501-804-9298
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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