=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326854514
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KNO'QOTI NATIVE WELLNESS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2024
-----------------------------------------------------
Last Update Date | 04/25/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 809 S MAIN ST
-----------------------------------------------------
City | LAKEPORT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95453-5510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-900-2121
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 809 S MAIN ST
-----------------------------------------------------
City | LAKEPORT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95453-5510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-900-2121
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | KYLE BILL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 707-900-2121
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172V00000X
-----------------------------------------------------
Taxonomy Name | Community Health Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 174H00000X
-----------------------------------------------------
Taxonomy Name | Health Educator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251X00000X
-----------------------------------------------------
Taxonomy Name | Supports Brokerage Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 332U00000X
-----------------------------------------------------
Taxonomy Name | Home Delivered Meals
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 385H00000X
-----------------------------------------------------
Taxonomy Name | Respite Care
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------