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General NPI Number Information
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NPI Number | 1881076859
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Entity Type | Organization
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Legal Business Name | AKASHA WELLNESS
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Dates
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Enumeration Date | 06/25/2015
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Last Update Date | 06/25/2015
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Provider Practice Location Address
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Address Line | 350 ZACH LN
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City | OZARK
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State | IL
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Zip | 62972-1119
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Country | US
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Telephone | 618-889-9570
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Fax |
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Provider Business Mailing Address
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Address Line | 350 ZACH LN
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City | OZARK
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State | IL
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Zip | 62972-1119
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | NICOLE LENCE
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Credential | MS, RDN, LDN
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Telephone | 618-889-9570
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 164.006153
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License Number State | IL
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