Provider Demographics
NPI:1073896700
Name:WHOLENESS MEDICAL SERVICES LLC
Entity Type:Organization
Organization Name:WHOLENESS MEDICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:SHANNON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:970-221-1106
Mailing Address - Street 1:2620 E PROSPECT RD STE 190
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-9098
Mailing Address - Country:US
Mailing Address - Phone:970-221-1106
Mailing Address - Fax:970-232-1050
Practice Address - Street 1:2620 E PROSPECT RD STE 190
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80525-9098
Practice Address - Country:US
Practice Address - Phone:970-221-1106
Practice Address - Fax:970-232-1050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31090207Q00000X, 207R00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty