Healthcare Provider Details

I. General information

NPI: 1295361509
Provider Name (Legal Business Name): UNBRIDLED HOLDINGS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2020
Last Update Date: 03/18/2020
Certification Date: 03/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9900 PRICE COFFEE RD
BENTONVILLE AR
72712
US

IV. Provider business mailing address

PO BOX 209
AVOCA AR
72711
US

V. Phone/Fax

Practice location:
  • Phone: 479-250-9838
  • Fax: 479-268-3473
Mailing address:
  • Phone: 479-250-9838
  • Fax: 479-268-3473

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: TERRICA LINN WEATHERFORD
Title or Position: PRESIDENT
Credential: MS, OTR/L
Phone: 501-240-5225