1154827863 NPI number — ADVANCED HEALTH AND WELLNESS AZ

Table of content: (NPI 1154827863)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154827863 NPI number — ADVANCED HEALTH AND WELLNESS AZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVANCED HEALTH AND WELLNESS AZ
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154827863
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/07/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4830 HIGHWAY 260 STE 102
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKESIDE
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85929-5851
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-537-7111
Provider Business Mailing Address Fax Number:
928-532-1129

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4830 HIGHWAY 260 STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKESIDE
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85929
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-537-7111
Provider Business Practice Location Address Fax Number:
928-532-1129
Provider Enumeration Date:
04/02/2018

Additional Information

Authorized Official

Authorized Official Last Name:
HALL
Authorized Official First Name:
HUGH
Authorized Official Middle Name:
RYAN
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
928-537-7111

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com