=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750957270
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AZ INTEGRATED MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2021
-----------------------------------------------------
Last Update Date | 06/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17431 N 71ST DR STE 102
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85308-8598
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-502-9487
-----------------------------------------------------
Fax | 855-313-5053
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7558 W THUNDERBIRD RD STE 1-460
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85381-6080
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-502-9487
-----------------------------------------------------
Fax | 855-313-5053
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. HEATHER L WOJSLAW
-----------------------------------------------------
Credential | NMD
-----------------------------------------------------
Telephone | 480-502-9487
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------