Healthcare Provider Details

I. General information

NPI: 1871861294
Provider Name (Legal Business Name): WOW FITNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2011
Last Update Date: 12/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5523 MABELVALE PIKE
LITTLE ROCK AR
72209-1823
US

IV. Provider business mailing address

5523 MABELVALE PIKE
LITTLE ROCK AR
72209-1823
US

V. Phone/Fax

Practice location:
  • Phone: 501-240-2773
  • Fax:
Mailing address:
  • Phone: 501-240-2773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberNETA
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberNETA
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License NumberNETA
License Number StateAR

VIII. Authorized Official

Name: KAMEELAH WESLEY
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 501-240-2773