1760760250 NPI number — NEW DIRECTIONS INTEGRATIVE WELLNESS CENTER OF WICKENBURG, ARIZONA, PLL

Table of content: (NPI 1760760250)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760760250 NPI number — NEW DIRECTIONS INTEGRATIVE WELLNESS CENTER OF WICKENBURG, ARIZONA, PLL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEW DIRECTIONS INTEGRATIVE WELLNESS CENTER OF WICKENBURG, ARIZONA, PLL
Provider Last Name:
Provider First Name:
Provider Middle Name:
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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:
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Provider Other Credential Text:
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NPI Number Information

NPI Number:
1760760250
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
370 PALM DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WICKENBURG
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85390
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-220-8216
Provider Business Mailing Address Fax Number:
716-408-1100

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
370 PALM DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WICKENBURG
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85390
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
928-220-8216
Provider Business Practice Location Address Fax Number:
716-408-1100
Provider Enumeration Date:
08/01/2011

Additional Information

Authorized Official

Authorized Official Last Name:
COBURN
Authorized Official First Name:
AMANDA
Authorized Official Middle Name:
RAE
Authorized Official Title or Position:
CHIEF OFFICE ADMINISTRATOR
Authorized Official Telephone Number:
716-307-5969

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  AP4081 , 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)





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