Healthcare Provider Details

I. General information

NPI: 1568638120
Provider Name (Legal Business Name): WELLNESS PROFESSIONALS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2008
Last Update Date: 05/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 MT VIEW AVE SUITE 102
LONGMONT CO
80501
US

IV. Provider business mailing address

833 INDEPENDENCE DR
LONGMONT CO
80501-3926
US

V. Phone/Fax

Practice location:
  • Phone: 303-702-1991
  • Fax: 303-776-1891
Mailing address:
  • Phone: 303-776-1879
  • Fax: 303-776-1891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number552
License Number StateCO

VIII. Authorized Official

Name: MRS. BONNIE EAN PETERSON
Title or Position: OWNER
Credential:
Phone: 303-776-1879