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General NPI Number Information
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NPI Number | 1982141149
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Entity Type | Organization
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Legal Business Name | IM A 10 WELLNESS CENTER, LLC
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Dates
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Enumeration Date | 01/26/2017
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Last Update Date | 06/16/2018
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Provider Practice Location Address
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Address Line | 404 LAKE WOOD DR
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City | SEARCY
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State | AR
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Zip | 72143-9056
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Country | US
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Telephone | 501-593-6997
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Fax | 501-325-2912
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Provider Business Mailing Address
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Address Line | 404 LAKE WOOD DR
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City | SEARCY
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State | AR
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Zip | 72143-9056
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Country | US
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Telephone | 501-593-6997
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Fax | 501-325-2912
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | SHIVONNE MARIE MCCARROLL
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Credential |
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Telephone | 501-593-6997
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 5940-C
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License Number State | AR
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