Provider Demographics
NPI:1801513114
Name:EDENMD WELLNESS LLC
Entity type:Organization
Organization Name:EDENMD WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN, PARTNER, ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RUTH
Authorized Official - Middle Name:
Authorized Official - Last Name:FORDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:956-607-4880
Mailing Address - Street 1:6620 E DESPERADO DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-5824
Mailing Address - Country:US
Mailing Address - Phone:956-607-4880
Mailing Address - Fax:
Practice Address - Street 1:7760 E STATE ROUTE 69 STE C5-342
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-2201
Practice Address - Country:US
Practice Address - Phone:602-525-8530
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-26
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty