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NPI Code Detail

MEDICARE: ADVANCED WELLNESS INFUSION CENTER, LLC

MEDICARE: ADVANCED WELLNESS INFUSION CENTER, LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1261QI0500XInfusion Therapy Clinic/Center

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDS5780OTHERAKSTATE OF ALASKA MEDICAL LICENSE

General Provider Information

NPI Number : 1366112856
Entity Type Code : Organization
Provider Name (Legal Business Name) : ADVANCED WELLNESS INFUSION CENTER, LLC
Provider Business Mailing Address
First Line : 5805 E COLUMBUS WAY
Second Line :
City : WASILLA
State : AK
Zip : 99654-7831
Country : US
Telephone Number : 907-929-4825
Fax Number :
Provider Business Practice Location Address
First Line : 5805 E COLUMBUS WAY
Second Line :
City : WASILLA
State : AK
Zip : 99654-7831
Country : US
Telephone Number : 907-929-4825
Fax Number :
Authorized Official
Title or Position : OWNER/PROVIDER
Name : NATHANIEL L EASTMAN
Credential : MD
Telephone Number : 907-980-1186
Provider Enumeration Date : 09/15/2021
Last Update Date : 03/07/2023

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