=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730922154
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED HEALING AND WELLNESS GROUP LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2024
-----------------------------------------------------
Last Update Date | 12/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 929 E COMMERCIAL AVE
-----------------------------------------------------
City | LOWELL
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46356-2307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-233-5400
-----------------------------------------------------
Fax | 219-292-4100
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 425 JOLIET ST STE 129-16
-----------------------------------------------------
City | DYER
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46311-1765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 219-233-5400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAMANAGER
-----------------------------------------------------
Name | DIANE OMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 219-233-5400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------