Provider Demographics
NPI:1013139401
Name:KIDZ KAN, LLC
Entity type:Organization
Organization Name:KIDZ KAN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:OTRL
Authorized Official - Phone:501-230-3100
Mailing Address - Street 1:130 UNDERHILL RD
Mailing Address - Street 2:
Mailing Address - City:BEEBE
Mailing Address - State:AR
Mailing Address - Zip Code:72012-9751
Mailing Address - Country:US
Mailing Address - Phone:501-230-3100
Mailing Address - Fax:501-882-2801
Practice Address - Street 1:27 HIGHWAY 64 WEST
Practice Address - Street 2:
Practice Address - City:BEEBE
Practice Address - State:AR
Practice Address - Zip Code:72012-2094
Practice Address - Country:US
Practice Address - Phone:501-230-3100
Practice Address - Fax:501-882-9825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR156889742Medicaid