Basic Information
| Provider Information | |||||||||
| NPI: | 1134847254 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORCHID ISLE WELLNESS CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10464 | ||||||||
| Address2: | |||||||||
| City: | HILO | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967215464 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704133776 | ||||||||
| FaxNumber: | 8335361752 | ||||||||
| Practice Location | |||||||||
| Address1: | 208 W NORTH ST STE 2 | ||||||||
| Address2: | |||||||||
| City: | CORTEZ | ||||||||
| State: | CO | ||||||||
| PostalCode: | 813213143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9704133776 | ||||||||
| FaxNumber: | 8335361752 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2022 | ||||||||
| LastUpdateDate: | 08/15/2022 | ||||||||
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| AuthorizedOfficialLastName: | COX | ||||||||
| AuthorizedOfficialFirstName: | ANN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9704133776 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | APN | ||||||||
| NPICertificationDate: | 08/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.