Provider Demographics
NPI:1194374876
Name:WELLNESS COLLECTIVE ARIZONA, LLC
Entity Type:Organization
Organization Name:WELLNESS COLLECTIVE ARIZONA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:RUNGE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:480-924-1987
Mailing Address - Street 1:3535 E BROWN RD STE 101
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-5602
Mailing Address - Country:US
Mailing Address - Phone:480-924-1987
Mailing Address - Fax:
Practice Address - Street 1:3535 E BROWN RD STE 101
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-5602
Practice Address - Country:US
Practice Address - Phone:480-924-1987
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center