Provider Demographics
NPI:1154198737
Name:PWWL CENTERS, LLC
Entity type:Organization
Organization Name:PWWL CENTERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:FREDERIKSEN
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:479-459-6354
Mailing Address - Street 1:PO BOX 6691
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-0601
Mailing Address - Country:US
Mailing Address - Phone:479-459-6354
Mailing Address - Fax:
Practice Address - Street 1:644 STATELINE RD
Practice Address - Street 2:
Practice Address - City:COLCORD
Practice Address - State:OK
Practice Address - Zip Code:74338-1344
Practice Address - Country:US
Practice Address - Phone:918-203-0004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health