Provider Demographics
NPI:1740651025
Name:MD WELLNESS CENTERS SCOTTSDALE LLC
Entity type:Organization
Organization Name:MD WELLNESS CENTERS SCOTTSDALE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUTHWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-535-4677
Mailing Address - Street 1:299 S MAIN ST
Mailing Address - Street 2:STE 1300
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-1919
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7555 E OSBORN RD
Practice Address - Street 2:STE 200
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-6434
Practice Address - Country:US
Practice Address - Phone:480-436-5151
Practice Address - Fax:480-436-5153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-13
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty