Provider Demographics
NPI:1609205863
Name:ADVANCED HEALTH & WELLNESS CENTER
Entity Type:Organization
Organization Name:ADVANCED HEALTH & WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:POOLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-315-8322
Mailing Address - Street 1:16421 N TATUM BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-3457
Mailing Address - Country:US
Mailing Address - Phone:480-315-8322
Mailing Address - Fax:
Practice Address - Street 1:16421 N TATUM BLVD STE 203
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-3457
Practice Address - Country:US
Practice Address - Phone:480-315-8322
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-07
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty