1083949358 NPI number — MILLENNIUM WELLNESS, LLC

Table of content: (NPI 1083949358)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083949358 NPI number — MILLENNIUM WELLNESS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MILLENNIUM 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:
1083949358
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/05/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
190 N GRAND MESA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CEDAREDGE
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81413-8388
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-856-4729
Provider Business Mailing Address Fax Number:
970-856-4734

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
190 N GRAND MESA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CEDAREDGE
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
81413-8388
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-856-4729
Provider Business Practice Location Address Fax Number:
970-856-4734
Provider Enumeration Date:
10/05/2009

Additional Information

Authorized Official

Authorized Official Last Name:
LAVALLEY
Authorized Official First Name:
KRISTIE
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
ACUPUNCTURIST
Authorized Official Telephone Number:
970-856-4729

Provider Taxonomy Codes

  • Taxonomy code: 261QP3300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QH0100X , with the licence number: 1293 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1760637508 . This is a "PERSONAL NPI" identifier , issued by the state of ( CO ) . This identifiers is of the category "OTHER".




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