=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962805812
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALLOPLASTIC RECONSTRUCTION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2014
-----------------------------------------------------
Last Update Date | 01/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6 W GE PATTERSON AVE SUITE 102
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38103-6413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-410-5375
-----------------------------------------------------
Fax | 800-977-4149
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 220 N. VAN BUREN
-----------------------------------------------------
City | LITTLE ROCK
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-265-0100
-----------------------------------------------------
Fax | 800-977-4149
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. MICHAEL D KACZKOWSKI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 501-265-0100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1700X
-----------------------------------------------------
Taxonomy Name | Ocularist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number | OPP00038
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 229N00000X
-----------------------------------------------------
Taxonomy Name | Anaplastologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------