Healthcare Provider Details

I. General information

NPI: 1396244505
Provider Name (Legal Business Name): VITRUVIAN DIETARY SOLUTIONS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2018
Last Update Date: 06/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2007 E NETTLETON AVE STE B
JONESBORO AR
72401-5286
US

IV. Provider business mailing address

2007 E NETTLETON AVE STE B
JONESBORO AR
72401-5286
US

V. Phone/Fax

Practice location:
  • Phone: 870-520-5013
  • Fax: 870-520-5020
Mailing address:
  • Phone: 870-520-5013
  • Fax: 870-520-5020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE-7271
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License NumberE-7271
License Number StateAR

VIII. Authorized Official

Name: BRADFORD STEWARD
Title or Position: OWNER
Credential: M.D.
Phone: 479-799-5520