MEDICARE: ALLEGIANT WELLNESS AND TESTOSTERONE REPLACEMENT, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1912430018
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALLEGIANT WELLNESS AND TESTOSTERONE REPLACEMENT, INC.

Provider Business Mailing Address
First Line	:	11121 N RODNEY PARHAM RD STE 2A
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72212-4158
Country	:	US
Telephone Number	:	501-503-9955
Fax Number	:

Provider Business Practice Location Address
First Line	:	11121 N RODNEY PARHAM RD STE 2A
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72212-4158
Country	:	US
Telephone Number	:	501-503-9955
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. JENNIFER L WALKER
Credential	:	DNP, AG-ACNP, TNCC
Telephone Number	:	501-503-9955

Provider Enumeration Date	:	04/05/2017
Last Update Date	:	04/05/2017

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