=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679837314
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LITTLE ROCK ENRICHMENT CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2012
-----------------------------------------------------
Last Update Date | 06/28/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13003 STACY LN
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72211-3238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-310-1150
-----------------------------------------------------
Fax | 501-353-0806
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13003 STACY LN
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72211-3238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-310-1150
-----------------------------------------------------
Fax | 501-353-0806
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/ DIRECTOR/ OWNER/ MANAGER
-----------------------------------------------------
Name | MR. DARIC LAMONT WASHINGTON
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 501-310-1150
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 149
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------