Basic Information
Provider Information | |||||||||
NPI: | 1043530017 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | KIDS FOR THE FUTURE OF FORREST CITY, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3998 HIGHWAY 1 N | ||||||||
Address2: | PO BOX 2192 | ||||||||
City: | FORREST CITY | ||||||||
State: | AR | ||||||||
PostalCode: | 723357637 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8706331737 | ||||||||
FaxNumber: | 8706331738 | ||||||||
Practice Location | |||||||||
Address1: | 3998 HIGHWAY 1 N | ||||||||
Address2: |   | ||||||||
City: | FORREST CITY | ||||||||
State: | AR | ||||||||
PostalCode: | 723357637 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8706331737 | ||||||||
FaxNumber: | 8706331738 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/01/2010 | ||||||||
LastUpdateDate: | 06/02/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HEISLER | ||||||||
AuthorizedOfficialFirstName: | THOMAS | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 8706331737 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PHD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133N00000X | 26859 | AR | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Nutritionist |   | 163W00000X | 26859 | AR | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse |   | 235Z00000X | 26859 | AR | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   | 225X00000X | 26859 | AR | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |   | 224Z00000X | 26859 | AR | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant |   | 225100000X | 26859 | AR | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 225200000X | 26859 | AR | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |   | 101YP2500X | 26859 | AR | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 252Y00000X | 26859 | AR | Y |   | Agencies | Early Intervention Provider Agency |   |
ID Information
ID | Type | State | Issuer | Description | 181130724 | 05 | AR |   | MEDICAID |