=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609413657
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAMELBACK NUTRITION & WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2019
-----------------------------------------------------
Last Update Date | 12/09/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9700 N 91ST ST STE A115
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85258-5036
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-403-9668
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10035 E CACTUS RD
-----------------------------------------------------
City | SCOTTSDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85260-5127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-403-9668
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KRISTEN CARLI
-----------------------------------------------------
Credential | RD
-----------------------------------------------------
Telephone | 602-403-9668
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------