=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508648320
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ACHIEVE HEALTH & WELLNESS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2023
-----------------------------------------------------
Last Update Date | 10/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6601 UNIVERSITY AVE UNIT 103E
-----------------------------------------------------
City | WINDSOR HEIGHTS
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50324-1600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 515-650-3122
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4100 OVID AVE
-----------------------------------------------------
City | DES MOINES
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 50310-4149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 505-604-3434
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | REBA EAGLES
-----------------------------------------------------
Credential | LAC
-----------------------------------------------------
Telephone | 505-604-3434
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------