=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053060004
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELLNESS REDISCOVERED P.L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2022
-----------------------------------------------------
Last Update Date | 08/24/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 705 E MAIN AVE
-----------------------------------------------------
City | BISMARCK
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58501-4525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-269-9455
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 705 E MAIN AVE
-----------------------------------------------------
City | BISMARCK
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58501-4525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DNP, APRN, FNP-C/OWNER
-----------------------------------------------------
Name | LAURA HOOVESTOL
-----------------------------------------------------
Credential | NURSE PRACTITIONER
-----------------------------------------------------
Telephone | 701-805-0870
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------