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General NPI Number Information
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NPI Number | 1154827863
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Entity Type | Organization
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Legal Business Name | ADVANCED HEALTH AND WELLNESS AZ
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Dates
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Enumeration Date | 04/02/2018
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Last Update Date | 06/07/2018
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Provider Practice Location Address
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Address Line | 4830 HIGHWAY 260 STE 102
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City | LAKESIDE
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State | AZ
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Zip | 85929
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Country | US
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Telephone | 928-537-7111
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Fax | 928-532-1129
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Provider Business Mailing Address
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Address Line | 4830 HIGHWAY 260 STE 102
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City | LAKESIDE
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State | AZ
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Zip | 85929-5851
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Country | US
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Telephone | 928-537-7111
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Fax | 928-532-1129
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | HUGH RYAN HALL
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Credential | DPM, MEDICAL DIRECTO
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Telephone | 928-537-7111
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State | AZ
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