Provider Demographics
NPI:1427379387
Name:FULL POTENTIAL
Entity Type:Organization
Organization Name:FULL POTENTIAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:N
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-374-0360
Mailing Address - Street 1:8109 INTERSTATE 30 ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72209
Mailing Address - Country:US
Mailing Address - Phone:501-374-0360
Mailing Address - Fax:501-374-0395
Practice Address - Street 1:8109 INTERSTATE 30
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72209-4840
Practice Address - Country:US
Practice Address - Phone:501-374-0360
Practice Address - Fax:501-374-0395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-15
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR27063261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR=========Medicaid