MEDICARE: THE TELOS CLINIC L.L.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1205601820
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE TELOS CLINIC L.L.C.

Provider Business Mailing Address
First Line	:	11917 SAINT CHARLES BLVD
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72211-2319
Country	:	US
Telephone Number	:	501-944-0659
Fax Number	:

Provider Business Practice Location Address
First Line	:	11917 SAINT CHARLES BLVD
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72211-2319
Country	:	US
Telephone Number	:	501-944-0659
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	ZACHERY OTWELL
Credential	:
Telephone Number	:	501-944-0659

Provider Enumeration Date	:	11/24/2023
Last Update Date	:	11/24/2023

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