=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457477564
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OASIS WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5860 S HOSPITAL DR SUITE 103
-----------------------------------------------------
City | GLOBE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85501-9449
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 928-425-2884
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 243
-----------------------------------------------------
City | GLOBE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85502-0243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MS. LEILA TODD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 928-200-2165
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | LT1717
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------