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General NPI Number Information
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NPI Number | 1518748524
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Entity Type | Organization
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Legal Business Name | EST IV HYDRATION & WELLNESS SPA PLLC
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Dates
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Enumeration Date | 10/06/2023
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Last Update Date | 12/26/2024
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Provider Practice Location Address
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Address Line | 9700 N 91ST ST STE A115
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City | SCOTTSDALE
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State | AZ
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Zip | 85258-5036
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Country | US
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Telephone | 520-510-0182
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Fax |
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Provider Business Mailing Address
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Address Line | 9700 N 91ST ST STE A115
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City | SCOTTSDALE
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State | AZ
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Zip | 85258-5036
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/ FAMILY NURSE PRACTITIONER
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Name | EBONIQUE THOMSON
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Credential | FNP
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Telephone | 520-510-0182
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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