Basic Information
| Provider Information | |||||||||
| NPI: | 1073896700 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WHOLENESS MEDICAL SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2620 E PROSPECT RD STE 190 | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805259098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702211106 | ||||||||
| FaxNumber: | 9702321050 | ||||||||
| Practice Location | |||||||||
| Address1: | 2620 E PROSPECT RD STE 190 | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805259098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702211106 | ||||||||
| FaxNumber: | 9702321050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2011 | ||||||||
| LastUpdateDate: | 09/20/2011 | ||||||||
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| AuthorizedOfficialLastName: | SHANNON | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 9702211106 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 31090 | CO | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | 31090 | CO | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363AM0700X | 31090 | CO | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.