Provider Demographics
NPI:1023601382
Name:ENGAGING LIFE INTEGRATED WELLNESS CENTER
Entity type:Organization
Organization Name:ENGAGING LIFE INTEGRATED WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MERCADO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-845-0767
Mailing Address - Street 1:12600 N. 13TH AVENUE
Mailing Address - Street 2:SUITE B8
Mailing Address - City:YOUNGTOWN
Mailing Address - State:AZ
Mailing Address - Zip Code:85363
Mailing Address - Country:US
Mailing Address - Phone:602-845-0767
Mailing Address - Fax:602-715-0647
Practice Address - Street 1:12600 N. 13TH AVENUE
Practice Address - Street 2:SUITE B8
Practice Address - City:YOUNGTOWN
Practice Address - State:AZ
Practice Address - Zip Code:85363
Practice Address - Country:US
Practice Address - Phone:602-845-0767
Practice Address - Fax:602-715-0647
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ENGAGING LIFE CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-02-18
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000001OtherNO NUMBER OBTAINED