1760801310 NPI number — FOUNDATIONS HEALTH AND WELLNESS CENTER LLC

Table of content: (NPI 1760801310)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760801310 NPI number — FOUNDATIONS HEALTH AND WELLNESS CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOUNDATIONS HEALTH AND WELLNESS CENTER 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:
MOUNT ANGEL CHIROPRACTIC
Provider Other Organization Name Type Code:
3
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:
1760801310
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
209 CROOKED CREEK LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HENDERSONVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37075-6713
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-949-0235
Provider Business Mailing Address Fax Number:
503-845-9373

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
393 E MAIN ST STE 8
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HENDERSONVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37075-2575
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-991-5951
Provider Business Practice Location Address Fax Number:
503-845-6030
Provider Enumeration Date:
04/10/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PETRACCI
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
JOHN
Authorized Official Title or Position:
OWNER/CHIROPRACTOR
Authorized Official Telephone Number:
615-991-5951

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)