Basic Information
| Provider Information | |||||||||
| NPI: | 1902234438 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SIRIUS HEALTH & WELLNESS LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4390 W FORT BRIDGER RD | ||||||||
| Address2: | |||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 863059038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9288998782 | ||||||||
| FaxNumber: | 9287715471 | ||||||||
| Practice Location | |||||||||
| Address1: | 3181 CLEARWATER DRIVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | PRESCOTT | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9288998782 | ||||||||
| FaxNumber: | 9287715471 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2013 | ||||||||
| LastUpdateDate: | 10/18/2013 | ||||||||
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| AuthorizedOfficialLastName: | KRUPNICK | ||||||||
| AuthorizedOfficialFirstName: | DEBRA | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PROVIDER | ||||||||
| AuthorizedOfficialTelephone: | 9288998782 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MS, FNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | APO522 | AZ | Y | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
ID Information
| ID | Type | State | Issuer | Description | 043346203012 | 01 | VT | TRICARE | OTHER | MB0243991 | 01 | VT | DEA | OTHER | ONP1198 | 05 | VT | MEDICAID | KRUP05338662 | 01 | VT | BLUE CROSS BLUE SHIELD | OTHER | 043346203 0078 | 01 | VT | CIGNA | OTHER |