=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346856341
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WHITE HORSE HEALTH AND WELLNESS CENTERS, LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/16/2020
-----------------------------------------------------
Last Update Date | 09/16/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 825 DELAWARE AVE STE 303C
-----------------------------------------------------
City | LONGMONT
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80501-6169
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-776-0995
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4125 PORTOFINO DR
-----------------------------------------------------
City | LONGMONT
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80503-4172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-717-4951
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. ROBERT M WELLS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 303-717-4951
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------