Healthcare Provider Details

I. General information

NPI: 1902962459
Provider Name (Legal Business Name): COLON ME CLEAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2236 E LOOP 820
FORT WORTH TX
76112-4013
US

IV. Provider business mailing address

2236 E LOOP 820
FORT WORTH TX
76112-4013
US

V. Phone/Fax

Practice location:
  • Phone: 817-451-0911
  • Fax: 817-451-0911
Mailing address:
  • Phone: 817-451-0911
  • Fax: 817-451-0911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number32695 16
License Number StateTX

VIII. Authorized Official

Name: MRS. YVONNE H. THOMAS
Title or Position: COLON HYDROTHERAPY
Credential: RMA
Phone: 817-366-0485