Provider Demographics
NPI:1699957928
Name:ALLOPLASTIC FACIAL RECONSTRUCTION
Entity type:Organization
Organization Name:ALLOPLASTIC FACIAL RECONSTRUCTION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:KACZKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-265-0100
Mailing Address - Street 1:3924 W MARKHAM ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5528
Mailing Address - Country:US
Mailing Address - Phone:501-265-0100
Mailing Address - Fax:501-265-0102
Practice Address - Street 1:3924 W MARKHAM ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5528
Practice Address - Country:US
Practice Address - Phone:501-265-0100
Practice Address - Fax:501-265-0102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-28
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02593066Medicaid
AR140207716Medicaid
AR49597OtherBCBS
AR4596730001Medicare NSC