Organization
360 WELLNESS CLINIC LLC
Active
Other names
West Side Wellness, The Shot Clinic
Organization subpart
No
Provider details
NPI number
Authorized official
BLAKE TORRES (OWNER)
(501) 778-3151
Entity
Organization
Contact information
Practice address
620 W SOUTH ST STE A, BENTON, AR 72015-4235
(501) 794-6123
(501) 794-6148
Mailing address
620 W SOUTH ST STE A, BENTON, AR 72015-4235
(501) 794-6123
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
—
—
261QR1300X
Rural Health Clinic/Center
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
119185001
—
AR
01
—
1205911849
NPI
AR
Enumeration date
12/09/2020
Last updated
05/09/2022
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