Provider Demographics
NPI:1154827863
Name:ADVANCED HEALTH AND WELLNESS AZ
Entity Type:Organization
Organization Name:ADVANCED HEALTH AND WELLNESS AZ
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HUGH
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM, MEDICAL DIRECTO
Authorized Official - Phone:928-537-7111
Mailing Address - Street 1:4830 HIGHWAY 260 STE 102
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-5851
Mailing Address - Country:US
Mailing Address - Phone:928-537-7111
Mailing Address - Fax:928-532-1129
Practice Address - Street 1:4830 HIGHWAY 260 STE 102
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929
Practice Address - Country:US
Practice Address - Phone:928-537-7111
Practice Address - Fax:928-532-1129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-02
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center