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General NPI Number Information
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NPI Number | 1972983286
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Entity Type | Organization
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Legal Business Name | QUINTESSENTIAL WELLNESS
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Dates
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Enumeration Date | 06/02/2015
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Last Update Date | 08/13/2015
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Provider Practice Location Address
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Address Line | 620 NC HIGHWAY 42 W
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City | CLAYTON
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State | NC
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Zip | 27520-5803
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Country | US
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Telephone | 919-400-7909
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Fax | 919-243-0530
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Provider Business Mailing Address
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Address Line | 620 NC HIGHWAY 42 W
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City | CLAYTON
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State | NC
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Zip | 27520-5803
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Country | US
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Telephone | 919-400-7909
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Fax | 919-243-0530
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Authorized Official
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Title or Position | OWNER
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Name | AMANDA R KEATES
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Credential | D.C
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Telephone | 919-400-7909
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 3960
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License Number State | NC
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