Healthcare Provider Details

I. General information

NPI: 1003675703
Provider Name (Legal Business Name): VITAL FUNCTION THERAPIES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2024
Last Update Date: 03/15/2024
Certification Date: 03/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

162 E SUNBRIDGE DR
FAYETTEVILLE AR
72703-2830
US

IV. Provider business mailing address

202 N WALTON BLVD STE 34
BENTONVILLE AR
72712-5175
US

V. Phone/Fax

Practice location:
  • Phone: 479-936-6119
  • Fax: 479-521-4161
Mailing address:
  • Phone: 479-936-6119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STACEY FLETCHER
Title or Position: OWNER
Credential: IBCLC
Phone: 479-936-6119