Provider Demographics
NPI:1932556461
Name:WELLNESS AND SPECIAL NEEDS CLINIC OF WEST ARKANSAS
Entity Type:Organization
Organization Name:WELLNESS AND SPECIAL NEEDS CLINIC OF WEST ARKANSAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:GIBBONS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:479-883-0240
Mailing Address - Street 1:8405 S ZERO ST STE C
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-7050
Mailing Address - Country:US
Mailing Address - Phone:479-883-0240
Mailing Address - Fax:479-782-3974
Practice Address - Street 1:8405 S ZERO ST STE C
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-7050
Practice Address - Country:US
Practice Address - Phone:479-883-0240
Practice Address - Fax:479-782-3974
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-13
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-3378261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care