Provider Demographics
NPI:1174938070
Name:ORGANIC HEALTH AND WELLNESS
Entity type:Organization
Organization Name:ORGANIC HEALTH AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:BROCK
Authorized Official - Last Name:JOHANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:480-313-1940
Mailing Address - Street 1:855 E BROWN RD STE 10
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85203-4949
Mailing Address - Country:US
Mailing Address - Phone:480-313-1940
Mailing Address - Fax:480-999-5708
Practice Address - Street 1:855 E BROWN RD STE 10
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85203-4949
Practice Address - Country:US
Practice Address - Phone:480-313-1940
Practice Address - Fax:480-999-5708
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-30
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8360111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty