Provider Demographics
NPI:1790124659
Name:KIDSCORP OF FAYETTEVILLE, INC
Entity Type:Organization
Organization Name:KIDSCORP OF FAYETTEVILLE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHELIA
Authorized Official - Middle Name:D
Authorized Official - Last Name:WILKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS, PT
Authorized Official - Phone:479-986-5150
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72757-0130
Mailing Address - Country:US
Mailing Address - Phone:479-856-6397
Mailing Address - Fax:479-856-6412
Practice Address - Street 1:2210 MAIN DR
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-6802
Practice Address - Country:US
Practice Address - Phone:479-856-6397
Practice Address - Fax:479-856-6412
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-24
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR28786261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR198277724Medicaid