Healthcare Provider Details

I. General information

NPI: 1548947872
Provider Name (Legal Business Name): INTERNATIONAL OKINAWAN KARATE ACADEMY & WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2023
Last Update Date: 06/29/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 W BELL RD STE 373
PHOENIX AZ
85023-3516
US

IV. Provider business mailing address

2902 W SWEETWATER AVE APT 1036
PHOENIX AZ
85029-1390
US

V. Phone/Fax

Practice location:
  • Phone: 888-516-1966
  • Fax:
Mailing address:
  • Phone: 888-516-1966
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code226000000X
TaxonomyRecreational Therapist Assistant
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. WALLACE CLYDE ANDREWS III
Title or Position: BHT/FACILITATOR/WELLNESS COACH
Credential: CHIEF INSTRUCTOR
Phone: 480-925-1393