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General NPI Number Information
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NPI Number | 1801513114
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Entity Type | Organization
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Legal Business Name | EDENMD WELLNESS LLC
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Dates
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Enumeration Date | 10/26/2022
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Last Update Date | 11/07/2022
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Provider Practice Location Address
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Address Line | 7760 E STATE ROUTE 69 STE C5-342
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City | PRESCOTT VALLEY
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State | AZ
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Zip | 86314-2201
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Country | US
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Telephone | 602-525-8530
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Fax |
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Provider Business Mailing Address
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Address Line | 6620 E DESPERADO DR
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City | PRESCOTT VALLEY
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State | AZ
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Zip | 86314-5824
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Country | US
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Telephone | 956-607-4880
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN, PARTNER, ADMINISTRATOR
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Name | DR. RUTH FORDE
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Credential | MD
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Telephone | 956-607-4880
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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