1811433212 NPI number — COPPER CANYON WELLNESS, LLC

Table of content: (NPI 1811433212)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811433212 NPI number — COPPER CANYON WELLNESS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COPPER CANYON WELLNESS, 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:
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:
1811433212
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/10/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1350 CENTRAL AVE
Provider Second Line Business Mailing Address:
SUITE 204
Provider Business Mailing Address City Name:
LOS ALAMOS
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87544-3244
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-660-2654
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1350 CENTRAL AVE
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
LOS ALAMOS
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87544-3244
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-660-2654
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/10/2017

Additional Information

Authorized Official

Authorized Official Last Name:
BARR
Authorized Official First Name:
DAWN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
505-660-2654

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  NM C4131 , 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: 81130210 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com