Provider Demographics
NPI:1932642105
Name:FOOTHILLS WELLNESS CENTER
Entity type:Organization
Organization Name:FOOTHILLS WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:BS, QMHP-A
Authorized Official - Phone:276-692-5934
Mailing Address - Street 1:405 PATRICK AVENUE
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:VA
Mailing Address - Zip Code:24171-0581
Mailing Address - Country:US
Mailing Address - Phone:276-694-2246
Mailing Address - Fax:276-694-4044
Practice Address - Street 1:405 PATRICK AVENUE
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:VA
Practice Address - Zip Code:24171-0581
Practice Address - Country:US
Practice Address - Phone:276-694-2246
Practice Address - Fax:276-694-4044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health