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General NPI Number Information
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NPI Number | 1831528207
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Entity Type | Organization
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Legal Business Name | OF THE EARTH WELLNESS
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Dates
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Enumeration Date | 11/06/2013
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Last Update Date | 11/06/2013
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Provider Practice Location Address
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Address Line | 6236 S 10TH ST
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City | PHOENIX
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State | AZ
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Zip | 85042-4312
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Country | US
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Telephone | 757-871-1880
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Fax |
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Provider Business Mailing Address
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Address Line | 6236 S 10TH ST
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City | PHOENIX
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State | AZ
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Zip | 85042-4312
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Country | US
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Telephone | 757-871-1880
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Fax |
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Authorized Official
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Title or Position | NATUROPATHIC MEDICAL DOCTOR
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Name | DR. DAVID LONGEVAL HAMILTON JR.
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Credential | N.M.D.
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Telephone | 757-871-1880
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 099.0099012
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License Number State | VT
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