Provider Demographics
NPI:1558012021
Name:ACHIEVE MORE SPORTS AND WELLNESS, PLLC
Entity Type:Organization
Organization Name:ACHIEVE MORE SPORTS AND WELLNESS, PLLC
Other - Org Name:ACHIEVE MORE SPORTS AND WELLNESS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:DAULT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:602-413-8710
Mailing Address - Street 1:PO BOX 6085
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85246-6085
Mailing Address - Country:US
Mailing Address - Phone:602-413-8710
Mailing Address - Fax:
Practice Address - Street 1:6139 S RURAL RD STE 102
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85283-2929
Practice Address - Country:US
Practice Address - Phone:480-846-0688
Practice Address - Fax:480-741-8650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-15
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ030026Medicaid