Healthcare Provider Details

I. General information

NPI: 1053825364
Provider Name (Legal Business Name): WELLNESS 1ST INTEGRATIVE MEDICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2017
Last Update Date: 04/20/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2451 E BASELINE RD STE 100
GILBERT AZ
85234
US

IV. Provider business mailing address

2451 E BASELINE RD STE 100
GILBERT AZ
85234-2467
US

V. Phone/Fax

Practice location:
  • Phone: 480-304-5152
  • Fax: 480-603-4147
Mailing address:
  • Phone: 480-304-5152
  • Fax: 480-603-4147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BD1200X
TaxonomyDialysis Equipment & Supplies (DME)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberRN06371
License Number StateAZ

VIII. Authorized Official

Name: DR. FARID ROOH
Title or Position: CLINIC DIRECTOR
Credential: DC
Phone: 480-304-5152