Provider Demographics
NPI:1447316237
Name:ALLAM DALATI
Entity type:Organization
Organization Name:ALLAM DALATI
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALLAM
Authorized Official - Middle Name:
Authorized Official - Last Name:DALATI
Authorized Official - Suffix:
Authorized Official - Credentials:CP
Authorized Official - Phone:479-685-0941
Mailing Address - Street 1:PO BOX 1972
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72757-1972
Mailing Address - Country:US
Mailing Address - Phone:479-685-0941
Mailing Address - Fax:479-621-9960
Practice Address - Street 1:112 N 34TH ST
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72756
Practice Address - Country:US
Practice Address - Phone:479-685-0941
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic FitterGroup - Multi-Specialty
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR4086630001Medicare ID - Type Unspecified