Provider Demographics
NPI:1013528017
Name:VITAL WELLNESS CLINIC LLC
Entity Type:Organization
Organization Name:VITAL WELLNESS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:WHITED
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:870-636-9218
Mailing Address - Street 1:4001 COMMERCIAL CENTER DR STE 1
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:AR
Mailing Address - Zip Code:72364-9616
Mailing Address - Country:US
Mailing Address - Phone:870-636-9218
Mailing Address - Fax:
Practice Address - Street 1:4001 COMMERCIAL CENTER DR STE 1
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:AR
Practice Address - Zip Code:72364-9616
Practice Address - Country:US
Practice Address - Phone:870-636-9218
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-12
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty