Healthcare Provider Details

I. General information

NPI: 1366089427
Provider Name (Legal Business Name): WEST MEMPHIS WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2019
Last Update Date: 12/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 W BROADWAY ST
WEST MEMPHIS AR
72301-2912
US

IV. Provider business mailing address

362 E KENNEDY BLVD
LAKEWOOD NJ
08701-1434
US

V. Phone/Fax

Practice location:
  • Phone: 718-838-1500
  • Fax:
Mailing address:
  • Phone: 718-838-1500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: JACOB TAUB
Title or Position: MEMBER
Credential:
Phone: 718-838-1500