| Restored Life Services Of Arkansas Inc | |
|
107 N Boston Pl Russellville AR 72801-3940 | |
| (479) 219-4100 | |
| (479) 222-0049 |
| Full Name | Restored Life Services Of Arkansas Inc |
|---|---|
| Speciality | Counselor |
| Location | 107 N Boston Pl, Russellville, Arkansas |
| Authorized Official Name and Position | Elvera Ruth Crawford (PRESIDENT) |
| Authorized Official Contact | 4792194100 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Restored Life Services Of Arkansas Inc 107 N Boston Place Russellville AR 72801 Ph: (479) 219-4100 | Restored Life Services Of Arkansas Inc 107 N Boston Pl Russellville AR 72801-3940 Ph: (479) 219-4100 |
| NPI Number | 1558727024 |
|---|---|
| Provider Enumeration Date | 01/13/2016 |
| Last Update Date | 05/21/2025 |
| Certification Date | 12/17/2024 |
| Medicare PECOS PAC ID | 8123555703 |
|---|---|
| Medicare Enrollment ID | O20241219004429 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1558727024 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YA0400X | Counselor - Addiction (substance Use Disorder) | (* (Not Available)) | Primary |
| Provider Name | Paul T Hickerson |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1134411036 PECOS PAC ID: 5294186326 Enrollment ID: I20240112001670 |
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