=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043824436
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SALVADOR INTEGRATIVE WELLNESS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2020
-----------------------------------------------------
Last Update Date | 08/17/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5148 VILLAGE CREEK DR STE 300
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75093-5064
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-661-1100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3839 MCKINNEY AVE STE 155 #2354
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75204-1488
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-699-9146
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MRS. JORDAN SARRA SALVADOR
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 214-699-9146
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------