Healthcare Provider Details

I. General information

NPI: 1881464154
Provider Name (Legal Business Name): CHOICE WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2024
Last Update Date: 01/08/2024
Certification Date: 01/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 N MESA DR STE 110
MESA AZ
85201-5974
US

IV. Provider business mailing address

460 N MESA DR STE 110
MESA AZ
85201-5974
US

V. Phone/Fax

Practice location:
  • Phone: 480-527-3873
  • Fax:
Mailing address:
  • Phone: 480-527-3873
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: IDOTEYEN SODIMU
Title or Position: CEO
Credential:
Phone: 480-527-3873