=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578375549
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN LEGACY OF LIFE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2025
-----------------------------------------------------
Last Update Date | 08/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1300 WILSON RD
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72205-6634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-907-9150
-----------------------------------------------------
Fax | 501-694-3112
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1300 WILSON RD
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72205-6634
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-907-9150
-----------------------------------------------------
Fax | 501-694-3112
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCE OPERATING OFFICER
-----------------------------------------------------
Name | TASHA RENEE FLOWERS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 501-907-9124
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335U00000X
-----------------------------------------------------
Taxonomy Name | Organ Procurement Organization
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------