=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346878691
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ASPEN MINISTRIES SYRINGA WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2020
-----------------------------------------------------
Last Update Date | 03/31/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1609 S KIMBALL AVE STE 200
-----------------------------------------------------
City | CALDWELL
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83605-5196
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-899-8101
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1609 S KIMBALL AVE STE 200
-----------------------------------------------------
City | CALDWELL
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83605-5196
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER/OVERSEER
-----------------------------------------------------
Name | ASPEN MORROW
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-899-8101
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 175T00000X
-----------------------------------------------------
Taxonomy Name | Peer Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------