Healthcare Provider Details

I. General information

NPI: 1144135625
Provider Name (Legal Business Name): VIVACITY 360 HEALTH CO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 N LIVERMORE ST
HAZEN AR
72064
US

IV. Provider business mailing address

2342 HIGHWAY 31 N
BEEBE AR
72012-9780
US

V. Phone/Fax

Practice location:
  • Phone: 501-232-1107
  • Fax: 501-426-8339
Mailing address:
  • Phone: 501-991-0163
  • Fax: 501-426-8339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. CANDICE ANN FORTE
Title or Position: CEO
Credential: APRN
Phone: 501-954-0443