Healthcare Provider Details

I. General information

NPI: 1366048803
Provider Name (Legal Business Name): 360 WELLNESS CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2020
Last Update Date: 05/09/2022
Certification Date: 05/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 W SOUTH ST STE A
BENTON AR
72015-4235
US

IV. Provider business mailing address

620 W SOUTH ST STE A
BENTON AR
72015-4235
US

V. Phone/Fax

Practice location:
  • Phone: 501-794-6123
  • Fax: 501-794-6148
Mailing address:
  • Phone: 501-794-6123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BLAKE TORRES
Title or Position: OWNER
Credential:
Phone: 501-778-3151