Basic Information
| Provider Information | |||||||||
| NPI: | 1912325515 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KIDS UNLIMITED LEARNING ACADEMY OF FT. SMITH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5400 EUPER LN | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729033232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797556601 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5400 EUPER LN | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729033232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797556601 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2014 | ||||||||
| LastUpdateDate: | 02/16/2016 | ||||||||
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| AuthorizedOfficialLastName: | KELLER | ||||||||
| AuthorizedOfficialFirstName: | SHELLY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4797556601 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 198333724 | 05 | AR | MEDICAID |