Provider Demographics
NPI:1215794599
Name:CLEAR CREEK WELLNESS
Entity type:Organization
Organization Name:CLEAR CREEK WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HERON
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:479-283-9958
Mailing Address - Street 1:2811 SPRINGDALE AVE # 8050
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-4358
Mailing Address - Country:US
Mailing Address - Phone:479-283-9958
Mailing Address - Fax:
Practice Address - Street 1:5203 WILLOW CREEK DR STE B
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-0876
Practice Address - Country:US
Practice Address - Phone:479-301-8970
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-04
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty