Provider Demographics
NPI:1811221468
Name:ALTA WELLNESS LLC
Entity type:Organization
Organization Name:ALTA WELLNESS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIS
Authorized Official - Middle Name:HERALD
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:210-930-5505
Mailing Address - Street 1:602 ALTA AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78209-4432
Mailing Address - Country:US
Mailing Address - Phone:210-930-5505
Mailing Address - Fax:
Practice Address - Street 1:1201 N LOOP 1604 W
Practice Address - Street 2:SUITE 117
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-4597
Practice Address - Country:US
Practice Address - Phone:210-493-3338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-30
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX6389770001Medicare NSC