Provider Demographics
NPI:1174905038
Name:THE SOURCE NATUROPATHIC MEDICAL CLINIC
Entity type:Organization
Organization Name:THE SOURCE NATUROPATHIC MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HELIOTI
Authorized Official - Suffix:
Authorized Official - Credentials:NMD
Authorized Official - Phone:585-469-9067
Mailing Address - Street 1:550 W. INDIAN SCHOOL RD SUITE 122
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013
Mailing Address - Country:US
Mailing Address - Phone:602-234-1158
Mailing Address - Fax:602-234-9691
Practice Address - Street 1:550 W INDIAN SCHOOL RD STE 122
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-3200
Practice Address - Country:US
Practice Address - Phone:602-234-1158
Practice Address - Fax:602-234-9691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-26
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ15-1492261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service