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General NPI Number Information
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NPI Number | 1043092257
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Entity Type | Organization
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Legal Business Name | EARTH REMEDY OPTIMAL WELLNESS LLC
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Dates
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Enumeration Date | 10/23/2023
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Last Update Date | 10/23/2023
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Provider Practice Location Address
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Address Line | 417 GREENLEE RD
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City | JOHNSON CITY
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State | TN
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Zip | 37601-7064
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Country | US
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Telephone | 423-302-0205
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Fax | 423-220-8582
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Provider Business Mailing Address
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Address Line | 417 GREENLEE RD
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City | JOHNSON CITY
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State | TN
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Zip | 37601-7064
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Country | US
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Telephone | 423-302-0205
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Fax | 423-220-8285
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Authorized Official
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Title or Position | OWNER
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Name | UBUNIBI-AFIA AGBENYAGA SHORT
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Credential | DIVINE
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Telephone | 423-880-3621
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 172V00000X
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Taxonomy Name | Community Health Worker
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 332BC3200X
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Taxonomy Name | Customized Equipment (DME)
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 171400000X
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Taxonomy Name | Health & Wellness Coach
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License Number |
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License Number State |
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