Provider Demographics
NPI:1871861294
Name:WOW FITNESS
Entity Type:Organization
Organization Name:WOW FITNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KAMEELAH
Authorized Official - Middle Name:
Authorized Official - Last Name:WESLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-240-2773
Mailing Address - Street 1:5523 MABELVALE PIKE
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72209-1823
Mailing Address - Country:US
Mailing Address - Phone:501-240-2773
Mailing Address - Fax:
Practice Address - Street 1:5523 MABELVALE PIKE
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72209-1823
Practice Address - Country:US
Practice Address - Phone:501-240-2773
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-13
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARNETA133NN1002X, 174H00000X, 302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Single Specialty
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Single Specialty
No302R00000XManaged Care OrganizationsHealth Maintenance OrganizationGroup - Single Specialty