Healthcare Provider Details

I. General information

NPI: 1376372078
Provider Name (Legal Business Name): I AM WELLNESS AZ LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2024
Last Update Date: 08/02/2024
Certification Date: 08/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24601 N 29TH AVE STE 157
PHOENIX AZ
85083-1165
US

IV. Provider business mailing address

898 N 1200 W STE 201
OREM UT
84057-3558
US

V. Phone/Fax

Practice location:
  • Phone: 480-900-9355
  • Fax:
Mailing address:
  • Phone: 385-499-5349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SARA RATNER
Title or Position: PRESIDENT, GOVERNMENT PROGRAMS
Credential:
Phone: 480-900-9355