Provider Demographics
NPI:1962805812
Name:ALLOPLASTIC RECONSTRUCTION
Entity type:Organization
Organization Name:ALLOPLASTIC RECONSTRUCTION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
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 1:220 N. VAN BUREN
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205
Mailing Address - Country:US
Mailing Address - Phone:501-265-0100
Mailing Address - Fax:800-977-4149
Practice Address - Street 1:6 W GE PATTERSON AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-6413
Practice Address - Country:US
Practice Address - Phone:901-410-5375
Practice Address - Fax:800-977-4149
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ALLOPLASTIC RECONSTRUCTION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-10-07
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
156FX1700X, 229N00000X
AROPP00038335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes229N00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersAnaplastologistGroup - Multi-Specialty
No156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularistGroup - Multi-Specialty
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Multi-Specialty