Healthcare Provider Details

I. General information

NPI: 1164349544
Provider Name (Legal Business Name): SUMMIT WELLNESS OF DPSW LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 W SOUTHERN AVE STE 23
MESA AZ
85210-5030
US

IV. Provider business mailing address

2329 EDENBORN AVE
METAIRIE LA
70001-1815
US

V. Phone/Fax

Practice location:
  • Phone: 602-513-7722
  • Fax: 480-850-5860
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: NICK GWYN
Title or Position: COO
Credential:
Phone: 504-571-5355