1669978391 NPI number — EDOE LLC

Table of content: (NPI 1669978391)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669978391 NPI number — EDOE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDOE LLC
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:
HELLO WELLNESS THERAPY
Provider Other Organization Name Type Code:
3
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:
1669978391
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/02/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7430 OLD SANTA FE TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA FE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87505-4574
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-473-6191
Provider Business Mailing Address Fax Number:
505-983-0833

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
518 OLD SANTA FE TRL STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANTA FE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87505-0398
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-473-6191
Provider Business Practice Location Address Fax Number:
505-819-1492
Provider Enumeration Date:
04/02/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DOERWALD
Authorized Official First Name:
ERIN
Authorized Official Middle Name:
SIBLEY
Authorized Official Title or Position:
PROVIDER
Authorized Official Telephone Number:
505-473-6191

Provider Taxonomy Codes

  • Taxonomy code: 261QM0855X , with the licence number:  C-09941 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2837987 . This is a "SCC#" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".