Provider Demographics
NPI:1851551386
Name:SELF RELIANCE LLC
Entity Type:Organization
Organization Name:SELF RELIANCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MAGOMED
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAIDAKOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-658-8057
Mailing Address - Street 1:500 S UNIVERSITY AVE
Mailing Address - Street 2:SUITE A-14
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-5302
Mailing Address - Country:US
Mailing Address - Phone:501-671-6200
Mailing Address - Fax:501-671-6205
Practice Address - Street 1:500 S UNIVERSITY AVE
Practice Address - Street 2:SUITE A-14
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-5302
Practice Address - Country:US
Practice Address - Phone:501-671-6200
Practice Address - Fax:501-671-6205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR175796716Medicaid
AR6166100001Medicare NSC