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General NPI Number Information
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NPI Number | 1881062628
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Entity Type | Organization
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Legal Business Name | RADIANT VIBE WELLNESS SPA LLC
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Dates
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Enumeration Date | 09/10/2015
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Last Update Date | 09/10/2015
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Provider Practice Location Address
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Address Line | 2800 S UNIVERSITY AVE
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City | LITTLE ROCK
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State | AR
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Zip | 72204-6006
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Country | US
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Telephone | 501-565-1888
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 6038
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City | JACKSONVILLE
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State | AR
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Zip | 72078-6038
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Country | US
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Telephone | 501-565-1888
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Fax |
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Authorized Official
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Title or Position | NURSE PRACTITIONER
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Name | APRIL J ELLIS
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Credential | NP
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Telephone | 501-565-1888
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | A03714
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License Number State | TX
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