Provider Demographics
NPI:1376001172
Name:LARISA KACHOWSKI, MD
Entity Type:Organization
Organization Name:LARISA KACHOWSKI, MD
Other - Org Name:LARISA KACHOWSKI FAMILY MEDICINE, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARISA
Authorized Official - Middle Name:
Authorized Official - Last Name:KACHOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-502-4071
Mailing Address - Street 1:3 STRATFORD LN
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-7527
Mailing Address - Country:US
Mailing Address - Phone:501-502-4071
Mailing Address - Fax:
Practice Address - Street 1:1726 W 42D AVE
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-7160
Practice Address - Country:US
Practice Address - Phone:501-502-4071
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-11
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1023214574OtherNPPES