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General NPI Number Information
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NPI Number | 1851805493
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Entity Type | Organization
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Legal Business Name | ACTIVE LIFE ACUPUNCTURE & WELLNESS CENTER
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Dates
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Enumeration Date | 11/17/2017
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Last Update Date | 11/17/2017
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Provider Practice Location Address
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Address Line | 2592 N GREGG AVE STE 10
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City | FAYETTEVILLE
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State | AR
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Zip | 72703-5520
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Country | US
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Telephone | 479-358-7690
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Fax |
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Provider Business Mailing Address
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Address Line | 2592 N GREGG AVE STE 10
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City | FAYETTEVILLE
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State | AR
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Zip | 72703-5520
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/PRACTITIONER
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Name | HAYDEN HENNINGSEN
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Credential |
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Telephone | 479-358-7690
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | 065
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License Number State | AR
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