Basic Information
| Provider Information | |||||||||
| NPI: | 1265055461 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WHOLENESS HEALTH, 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: | 05/21/2020 | ||||||||
| LastUpdateDate: | 05/21/2020 | ||||||||
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| AuthorizedOfficialLastName: | SHANNON | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
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| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 9702249458 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WHOLENESS HEALTH, LLC | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 05/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | N | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health | 261QR1100X | N | Ambulatory Health Care Facilities | Clinic/Center | Research | 363LF0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.