Provider Demographics
NPI:1992973119
Name:WELLNESS PROFESSIONALS, INC.
Entity type:Organization
Organization Name:WELLNESS PROFESSIONALS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:DICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:479-444-9449
Mailing Address - Street 1:2592 N. GREGG AVENUE
Mailing Address - Street 2:STE. 1
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-5528
Mailing Address - Country:US
Mailing Address - Phone:479-444-9449
Mailing Address - Fax:479-444-9403
Practice Address - Street 1:2592 N. GREGG AVENUE
Practice Address - Street 2:STE. 1
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-5528
Practice Address - Country:US
Practice Address - Phone:479-444-9449
Practice Address - Fax:479-444-9403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-11
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR1533111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5Y970Medicare PIN
ARU81035Medicare UPIN
AR5U759Medicare PIN
AR5F956Medicare PIN