Provider Demographics
NPI:1063903748
Name:WELL LIFE FAMILY MEDICINE INC
Entity type:Organization
Organization Name:WELL LIFE FAMILY MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:D.O./ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:LEDBETTER
Authorized Official - Suffix:
Authorized Official - Credentials:DO,MBA
Authorized Official - Phone:479-782-6318
Mailing Address - Street 1:1623 ROGERS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72901-3826
Mailing Address - Country:US
Mailing Address - Phone:479-782-6318
Mailing Address - Fax:479-782-7028
Practice Address - Street 1:1623 ROGERS AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-3826
Practice Address - Country:US
Practice Address - Phone:479-782-6318
Practice Address - Fax:479-782-7028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-29
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ART2018-104208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty