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General NPI Number Information
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NPI Number | 1932556461
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Entity Type | Organization
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Legal Business Name | WELLNESS AND SPECIAL NEEDS CLINIC OF WEST ARKANSAS
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Dates
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Enumeration Date | 05/13/2016
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Last Update Date | 05/13/2016
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Provider Practice Location Address
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Address Line | 8405 S ZERO ST STE C
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City | FORT SMITH
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State | AR
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Zip | 72903-7050
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Country | US
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Telephone | 479-883-0240
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Fax | 479-782-3974
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Provider Business Mailing Address
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Address Line | 8405 S ZERO ST STE C
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City | FORT SMITH
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State | AR
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Zip | 72903-7050
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Country | US
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Telephone | 479-883-0240
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Fax | 479-782-3974
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Authorized Official
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Title or Position | OWNER
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Name | DR. GLENN GREGORY GIBBONS
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Credential | MD
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Telephone | 479-883-0240
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | E-3378
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License Number State | AR
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