Healthcare Provider Details

I. General information

NPI: 1417727157
Provider Name (Legal Business Name): INDIGENOUS WELLNESS ALLIANCE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2024
Last Update Date: 12/15/2024
Certification Date: 12/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 TALMAGE RD
UKIAH CA
95482-5956
US

IV. Provider business mailing address

705 N STATE ST # 417
UKIAH CA
95482-3407
US

V. Phone/Fax

Practice location:
  • Phone: 707-234-0086
  • Fax:
Mailing address:
  • Phone: 707-234-0086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. DIANA BILLY-ELLIOTT
Title or Position: CEO
Credential:
Phone: 707-234-0086