Healthcare Provider Details

I. General information

NPI: 1992695316
Provider Name (Legal Business Name): ADVANCED WELLNESS HOMES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2025
Last Update Date: 07/07/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 S PLAZA DR APT 3070
TEMPE AZ
85282-1058
US

IV. Provider business mailing address

2520 S PLAZA DR APT 3070
TEMPE AZ
85282-1058
US

V. Phone/Fax

Practice location:
  • Phone: 507-884-3032
  • Fax:
Mailing address:
  • Phone: 507-884-3032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: OMAR IDIRIS
Title or Position: OWNER
Credential:
Phone: 507-884-3032