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General NPI Number Information
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NPI Number | 1285229856
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Entity Type | Organization
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Legal Business Name | HOMETOWN WELLNESS PLLC
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Dates
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Enumeration Date | 03/05/2021
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Last Update Date | 03/05/2021
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Provider Practice Location Address
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Address Line | 45 S REDWOOD ST # 750
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City | COLORADO CITY
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State | AZ
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Zip | 86021-6322
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Country | US
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Telephone | 928-377-0629
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 750
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City | COLORADO CITY
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State | AZ
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Zip | 86021-0750
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Country | US
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Telephone | 928-377-0629
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. THEIL L COOKE JR.
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Credential | FNP
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Telephone | 928-377-0629
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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