Provider Demographics
NPI:1629226816
Name:WELLNESS TODAY MEDICAL CLINIC, INC.
Entity Type:Organization
Organization Name:WELLNESS TODAY MEDICAL CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHANAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-974-6611
Mailing Address - Street 1:13090 N 94TH DR
Mailing Address - Street 2:# 204
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4256
Mailing Address - Country:US
Mailing Address - Phone:623-972-6700
Mailing Address - Fax:
Practice Address - Street 1:13090 N 94TH DR
Practice Address - Street 2:# 204
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4256
Practice Address - Country:US
Practice Address - Phone:623-972-6700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-03
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10747207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZC99037Medicare UPIN
AZZ124626Medicare PIN