Provider Demographics
NPI:1417669029
Name:NORTHWEST ARKANSAS FUNCTIONAL HEALTH LLC
Entity Type:Organization
Organization Name:NORTHWEST ARKANSAS FUNCTIONAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ARPN
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-220-9951
Mailing Address - Street 1:20398 BILL YOUNG RD
Mailing Address - Street 2:
Mailing Address - City:SILOAM SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:72761-8921
Mailing Address - Country:US
Mailing Address - Phone:479-220-9909
Mailing Address - Fax:888-675-9637
Practice Address - Street 1:246 S MAESTRI RD STE 2
Practice Address - Street 2:
Practice Address - City:TONTITOWN
Practice Address - State:AR
Practice Address - Zip Code:72762-9703
Practice Address - Country:US
Practice Address - Phone:479-220-9909
Practice Address - Fax:888-675-9637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-15
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty