NPIMap

Organization Active NPI

360 Wellness Clinic LLC

  • Clinic/Center
  • Benton, AR
National Provider Identifier
1366048803
Registry record updated May 9, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinic/CenterTaxonomy code 261Q00000X
Legal business name
360 WELLNESS CLINIC LLC
Practice address
620 W South St Ste a
Benton, AR 72015-4235
Phone
(501) 794-6123
Fax
(501) 794-6148
NPI assigned
Dec 9, 2020
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 9, 2022

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

Authorized official

Name
Blake Torres
Title
Owner
Phone
(501) 778-3151

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X Primary
Rural Health Clinic/Center 261QR1300X

Addresses

Primary practice location

620 W South St Ste a
Benton, AR 72015-4235

Mailing address

620 W South St Ste a
Benton, AR 72015-4235
Phone (501) 794-6123

Other identifiers 2

IdentifierTypeStateIssuer
119185001MedicaidAR
1205911849OtherARNPI

Other names 2

  • The Shot Clinic Doing business as
  • West Side Wellness Doing business as

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 2

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

NPI Registry JSON

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

{
    "created_epoch": "1607472000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1652054400000",
    "number": "1366048803",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "620 W SOUTH ST STE A",
            "city": "BENTON",
            "state": "AR",
            "postal_code": "720154235",
            "telephone_number": "501-794-6123"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "620 W SOUTH ST STE A",
            "city": "BENTON",
            "state": "AR",
            "postal_code": "720154235",
            "telephone_number": "501-794-6123",
            "fax_number": "501-794-6148"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "360 WELLNESS CLINIC LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-12-09",
        "last_updated": "2022-05-09",
        "certification_date": "2022-05-09",
        "status": "A",
        "authorized_official_last_name": "TORRES",
        "authorized_official_first_name": "BLAKE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "501-778-3151"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "119185001",
            "state": "AR"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NPI",
            "identifier": "1205911849",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "The Shot Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "West Side Wellness",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "West Side Wellness",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Benton, AR

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 9, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.