Provider Demographics
NPI:1598049744
Name:ALLOPLASTIC RECONSTRUCTION
Entity Type:Organization
Organization Name:ALLOPLASTIC RECONSTRUCTION
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 1:3924 W MARKHAM ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5528
Mailing Address - Country:US
Mailing Address - Phone:501-265-0100
Mailing Address - Fax:501-265-0102
Practice Address - Street 1:3924 W MARKHAM ST
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5528
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:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
156FX1700X, 174400000X, 229N00000X, 332BC3200X
AROPP00038335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1700XEye and Vision Services ProvidersTechnician/TechnologistOcularistGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No229N00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersAnaplastologistGroup - Multi-Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Multi-Specialty
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Multi-Specialty