Healthcare Provider Details

I. General information

NPI: 1073743399
Provider Name (Legal Business Name): ROLLER WEIGHT LOSS INSTITUTE,INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2009
Last Update Date: 08/06/2021
Certification Date: 08/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1695 E RAINFOREST RD
FAYETTEVILLE AR
72703-5385
US

IV. Provider business mailing address

1695 E RAINFOREST RD
FAYETTEVILLE AR
72703-5385
US

V. Phone/Fax

Practice location:
  • Phone: 479-445-6460
  • Fax: 479-445-6719
Mailing address:
  • Phone: 479-445-6460
  • Fax: 479-445-6719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberE5193
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JOSHUA ERNEST ROLLER
Title or Position: PRESIDENT/CEO
Credential: M.D.
Phone: 479-445-6460