1063780708 NPI number — SUPERSTITION WELLNESS CENTER PLLC

Table of content: (NPI 1063780708)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063780708 NPI number — SUPERSTITION WELLNESS CENTER PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUPERSTITION WELLNESS CENTER PLLC
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:
1063780708
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1100 S DOBSON RD
Provider Second Line Business Mailing Address:
SUITE 112
Provider Business Mailing Address City Name:
CHANDLER
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85286-6157
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-857-2098
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1946 S SIGNAL BUTTE RD
Provider Second Line Business Practice Location Address:
SUITE A105
Provider Business Practice Location Address City Name:
MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85209-2732
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-857-2098
Provider Business Practice Location Address Fax Number:
480-963-7097
Provider Enumeration Date:
12/08/2011

Additional Information

Authorized Official

Authorized Official Last Name:
WADE
Authorized Official First Name:
RYAN
Authorized Official Middle Name:
W
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
480-857-2098

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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