Provider Demographics
NPI:1972983286
Name:QUINTESSENTIAL WELLNESS
Entity Type:Organization
Organization Name:QUINTESSENTIAL WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:R
Authorized Official - Last Name:KEATES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:919-400-7909
Mailing Address - Street 1:620 NC HIGHWAY 42 W
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27520-5803
Mailing Address - Country:US
Mailing Address - Phone:919-400-7909
Mailing Address - Fax:919-243-0530
Practice Address - Street 1:620 NC HIGHWAY 42 W
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520-5803
Practice Address - Country:US
Practice Address - Phone:919-400-7909
Practice Address - Fax:919-243-0530
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-02
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3960261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty