Provider Demographics
NPI:1720751373
Name:OUR BROTHER'S KEEPER WELLNESS ORGANIZATION
Entity Type:Organization
Organization Name:OUR BROTHER'S KEEPER WELLNESS ORGANIZATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:MARYIE
Authorized Official - Last Name:BELL-BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-412-2268
Mailing Address - Street 1:PO BOX 46346
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72214-6346
Mailing Address - Country:US
Mailing Address - Phone:501-647-1042
Mailing Address - Fax:
Practice Address - Street 1:7101 W 12TH ST STE 200I
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204-2404
Practice Address - Country:US
Practice Address - Phone:501-647-1042
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-29
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)