1982968087 NPI number — CONTINUUM WELLNESS CLINIC, LLC

Table of content: (NPI 1982968087)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982968087 NPI number — CONTINUUM WELLNESS CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONTINUUM WELLNESS CLINIC, 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:
1982968087
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/17/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3941 E BASELINE RD
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
GILBERT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85234-2750
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-503-2010
Provider Business Mailing Address Fax Number:
480-503-2300

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3230 S GILBERT RD
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
CHANDLER
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85286-5110
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-629-5095
Provider Business Practice Location Address Fax Number:
480-629-5895
Provider Enumeration Date:
07/03/2012

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIDSON
Authorized Official First Name:
STEVE
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
616-356-5000

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  5014 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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