Healthcare Provider Details

I. General information

NPI: 1669386876
Provider Name (Legal Business Name): DIABETES & KIDNEY DISEASE PREVENTION PROGRAM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 FAIRWAY DR
PINE BLUFF AR
71603-8105
US

IV. Provider business mailing address

1007 FAIRWAY DR
PINE BLUFF AR
71603-8105
US

V. Phone/Fax

Practice location:
  • Phone: 870-718-6329
  • Fax:
Mailing address:
  • Phone: 870-718-6329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateNULL

VIII. Authorized Official

Name: NICOLE DANISE BATES
Title or Position: EXECUTIVE DIRECTOR, LIFESTYLE COACH
Credential: FNP-BC
Phone: 870-718-6329