Provider Demographics
NPI:1811426380
Name:ARKANSAS LONGEVITY CENTER, PLLC
Entity type:Organization
Organization Name:ARKANSAS LONGEVITY CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:OUMITANA
Authorized Official - Middle Name:
Authorized Official - Last Name:KAJKENOVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-904-5157
Mailing Address - Street 1:1509 DULLES DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-3718
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2300 ANDOVER CT STE 400
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72227-3990
Practice Address - Country:US
Practice Address - Phone:501-904-5157
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-08
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty