Provider Demographics
NPI:1881062628
Name:RADIANT VIBE WELLNESS SPA LLC
Entity type:Organization
Organization Name:RADIANT VIBE WELLNESS SPA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:APRIL
Authorized Official - Middle Name:J
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:501-565-1888
Mailing Address - Street 1:PO BOX 6038
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72078-6038
Mailing Address - Country:US
Mailing Address - Phone:501-565-1888
Mailing Address - Fax:
Practice Address - Street 1:2800 S UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204-6006
Practice Address - Country:US
Practice Address - Phone:501-565-1888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-10
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXA03714363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty