Healthcare Provider Details

I. General information

NPI: 1043092257
Provider Name (Legal Business Name): EARTH REMEDY OPTIMAL WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2023
Last Update Date: 10/23/2023
Certification Date: 10/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 GREENLEE RD
JOHNSON CITY TN
37601-7064
US

IV. Provider business mailing address

417 GREENLEE RD
JOHNSON CITY TN
37601-7064
US

V. Phone/Fax

Practice location:
  • Phone: 423-302-0205
  • Fax: 423-220-8582
Mailing address:
  • Phone: 423-302-0205
  • Fax: 423-220-8285

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: UBUNIBI-AFIA AGBENYAGA SHORT
Title or Position: OWNER
Credential: DIVINE
Phone: 423-880-3621