1245443662 NPI number — WISDOM TRADITIONS WELLNESS, LLC

Table of content: (NPI 1245443662)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245443662 NPI number — WISDOM TRADITIONS WELLNESS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WISDOM TRADITIONS 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:
1245443662
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/05/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
615 E 82ND AVENUE SUITE B-5
Provider Second Line Business Mailing Address:
SUITE #17
Provider Business Mailing Address City Name:
ANCHORAGE
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99518
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-644-0722
Provider Business Mailing Address Fax Number:
888-957-1346

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
615 E 82ND AVENUE SUITE B-5
Provider Second Line Business Practice Location Address:
SUITE #17
Provider Business Practice Location Address City Name:
ANCHORAGE
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99518
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-644-0722
Provider Business Practice Location Address Fax Number:
888-957-1346
Provider Enumeration Date:
05/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WARREN
Authorized Official First Name:
WANDA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER, THERAPIST
Authorized Official Telephone Number:
907-644-0722

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  88 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 1612 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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