Provider Demographics
NPI:1558727024
Name:RESTORED LIFE SERVICES OF ARKANSAS
Entity Type:Organization
Organization Name:RESTORED LIFE SERVICES OF ARKANSAS
Other - Org Name:RESTORED LIFE SERVICES
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:CAITLIN
Authorized Official - Last Name:CONNER
Authorized Official - Suffix:
Authorized Official - Credentials:LADAC, CRC
Authorized Official - Phone:479-219-4100
Mailing Address - Street 1:PO BOX 1483
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72811-1483
Mailing Address - Country:US
Mailing Address - Phone:479-219-4100
Mailing Address - Fax:
Practice Address - Street 1:127 E 3RD ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-5106
Practice Address - Country:US
Practice Address - Phone:479-219-4100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-13
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty