Healthcare Provider Details

I. General information

NPI: 1407783764
Provider Name (Legal Business Name): RENOVA WELLNESS & AESTHETICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 S WALTON BLVD STE 2
BENTONVILLE AR
72712-6235
US

IV. Provider business mailing address

5101 S SLOAN CIR
ROGERS AR
72758-4617
US

V. Phone/Fax

Practice location:
  • Phone: 479-593-3020
  • Fax: 479-341-9337
Mailing address:
  • Phone: 479-225-1750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BRANT KWYZLA
Title or Position: OWNER
Credential:
Phone: 479-225-1750