=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730093493
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KINSHIP PACE OF WESTERN ARKANSAS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2026
-----------------------------------------------------
Last Update Date | 09/30/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1000 S 21ST ST
-----------------------------------------------------
City | FORT SMITH
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72901-4008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-493-7608
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 225 CROSSWAYS PARK DR
-----------------------------------------------------
City | WOODBURY
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11797-2083
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | RYAN LEAHY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 845-235-6531
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251T00000X
-----------------------------------------------------
Taxonomy Name | PACE Provider Organization
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NULL
-----------------------------------------------------