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General NPI Number Information
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NPI Number | 1497369730
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Entity Type | Organization
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Legal Business Name | GREEN MOUNTAIN WELLNESS
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Dates
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Enumeration Date | 09/03/2020
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Last Update Date | 09/03/2020
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Provider Practice Location Address
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Address Line | 1059 N COLLEGE AVENUE PO
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City | THATCHER
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State | AZ
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Zip | 85365
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Country | US
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Telephone | 928-965-9545
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Fax | 928-350-8707
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Provider Business Mailing Address
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Address Line | 1059 N COLLEGE AVENUE PO
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City | THATCHER
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State | AZ
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Zip | 85365
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Country | US
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Telephone | 928-965-9545
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Fax | 928-350-8707
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Authorized Official
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Title or Position | OWNER
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Name | ALISSA STOCKTON
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Credential | D.O.M.
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Telephone | 928-965-9545
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number |
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License Number State |
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