Provider Demographics
NPI:1700253507
Name:NATURAL MEDICINE AND DETOX INC.
Entity type:Organization
Organization Name:NATURAL MEDICINE AND DETOX INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:FONTES
Authorized Official - Suffix:
Authorized Official - Credentials:LAC CCH
Authorized Official - Phone:602-307-0888
Mailing Address - Street 1:2701 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-1004
Mailing Address - Country:US
Mailing Address - Phone:602-307-0888
Mailing Address - Fax:602-307-1002
Practice Address - Street 1:2701 N 7TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-1004
Practice Address - Country:US
Practice Address - Phone:602-307-0888
Practice Address - Fax:602-307-1002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-27
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0680261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center