Provider Demographics
NPI:1235413485
Name:REAL LIFE SKIN
Entity Type:Organization
Organization Name:REAL LIFE SKIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KACZKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-265-0100
Mailing Address - Street 1:P O BOX 56182
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72215-6182
Mailing Address - Country:US
Mailing Address - Phone:501-265-0100
Mailing Address - Fax:501-265-0102
Practice Address - Street 1:220 N VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-3650
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:2011-10-06
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment