=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528502812
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ESSENTIAL HEALTH & WELLNESS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2016
-----------------------------------------------------
Last Update Date | 10/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1001 N BUCKNER ST
-----------------------------------------------------
City | DERBY
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67037-1824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-425-3337
-----------------------------------------------------
Fax | 316-425-3799
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1001 N BUCKNER ST
-----------------------------------------------------
City | DERBY
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67037-1824
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-425-3337
-----------------------------------------------------
Fax | 316-425-3799
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | AMANDA HELMS
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 316-425-3337
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------