Provider Demographics
NPI:1073743399
Name:ROLLER WEIGHT LOSS INSTITUTE,INC.
Entity Type:Organization
Organization Name:ROLLER WEIGHT LOSS INSTITUTE,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:ERNEST
Authorized Official - Last Name:ROLLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-445-6460
Mailing Address - Street 1:1695 E RAINFOREST RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-5385
Mailing Address - Country:US
Mailing Address - Phone:479-445-6460
Mailing Address - Fax:479-445-6719
Practice Address - Street 1:1695 E RAINFOREST RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-5385
Practice Address - Country:US
Practice Address - Phone:479-445-6460
Practice Address - Fax:479-445-6719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-21
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE5193174400000X
208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200624510AMedicaid
AR211552002Medicaid