NPIMap

Organization Active NPI

Pure Balance of Nwa PLLC

  • Psychiatry Physician
  • Rogers, AR
National Provider Identifier
1073359931
Registry record updated Aug 5, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Psychiatry PhysicianTaxonomy code 2084P0800X
Legal business name
PURE BALANCE OF NWA PLLC
Practice address
3608 W Southern Hills Blvd
Rogers, AR 72758-8013
Phone
(479) 633-7052
NPI assigned
Jul 1, 2024
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 5, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jacob Boydstun, DONPI 1568805299
Title
Owner
Phone
(432) 770-5923

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatry PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2084P0800X Primary

Addresses

Primary practice location

3608 W Southern Hills Blvd
Rogers, AR 72758-8013

Mailing address

3608 W Southern Hills Blvd
Rogers, AR 72758-8013
Phone (479) 633-7052

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AR

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20240821001375 AR Part B Supplier - Clinic/Group Practice 6901344928 Receives reassigned benefits from 12 practitioners
Practice locations: Rogers, AR

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
04D2320713Pure Balance of Nwa PLLC3608 W Southern Hills Blvd, Unit #4, Rogers, AR 72758Certificate of waiverMar 23, 2027

National Provider Directory

National Provider Directory

Locations

3608 W Southern Hills Blvd
Rogers, AR 72758
Phone (479) 633-7052

3608 W Southern Hills Blvd
Ste 4
Rogers, AR 72758
Phone (479) 318-2382

Practitioners & affiliated clinicians

Practitioners 13

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 13

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1719792000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1722816000000",
    "number": "1073359931",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3608 W SOUTHERN HILLS BLVD",
            "city": "ROGERS",
            "state": "AR",
            "postal_code": "727588013",
            "telephone_number": "479-633-7052"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3608 W SOUTHERN HILLS BLVD",
            "city": "ROGERS",
            "state": "AR",
            "postal_code": "727588013",
            "telephone_number": "479-633-7052"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PURE BALANCE OF NWA PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-07-01",
        "last_updated": "2024-08-05",
        "certification_date": "2024-07-23",
        "status": "A",
        "authorized_official_last_name": "BOYDSTUN",
        "authorized_official_first_name": "JACOB",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "432-770-5923",
        "authorized_official_credential": "DO"
    },
    "taxonomies": [
        {
            "code": "2084P0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Rogers, AR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 5, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.