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General NPI Number Information
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NPI Number | 1548940612
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Entity Type | Organization
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Legal Business Name | ARCHIE WELLNESS INC
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Dates
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Enumeration Date | 07/24/2023
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Last Update Date | 07/24/2023
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Provider Practice Location Address
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Address Line | 3120 N 19TH AVE STE 130
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City | PHOENIX
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State | AZ
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Zip | 85015-6061
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Country | US
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Telephone | 240-595-8743
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Fax |
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Provider Business Mailing Address
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Address Line | 3120 N 19TH AVE STE 130
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City | PHOENIX
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State | AZ
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Zip | 85015-6061
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Country | US
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Telephone | 240-595-8743
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. ISAAC MATOVU
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Credential | ADMINISTRATOR
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Telephone | 240-595-8743
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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