Provider Demographics
NPI:1285229856
Name:HOMETOWN WELLNESS PLLC
Entity Type:Organization
Organization Name:HOMETOWN WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:THEIL
Authorized Official - Middle Name:L
Authorized Official - Last Name:COOKE
Authorized Official - Suffix:JR
Authorized Official - Credentials:FNP
Authorized Official - Phone:928-377-0629
Mailing Address - Street 1:PO BOX 750
Mailing Address - Street 2:
Mailing Address - City:COLORADO CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86021-0750
Mailing Address - Country:US
Mailing Address - Phone:928-377-0629
Mailing Address - Fax:
Practice Address - Street 1:45 S REDWOOD ST # 750
Practice Address - Street 2:
Practice Address - City:COLORADO CITY
Practice Address - State:AZ
Practice Address - Zip Code:86021-6322
Practice Address - Country:US
Practice Address - Phone:928-377-0629
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty