Provider Demographics
NPI:1053798793
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:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:ARNESON
Authorized Official - Suffix:
Authorized Official - Credentials:NMD
Authorized Official - Phone:602-234-1158
Mailing Address - Street 1:1932 N MESA DR UNIT 9
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-1622
Mailing Address - Country:US
Mailing Address - Phone:707-540-1456
Mailing Address - Fax:
Practice Address - Street 1:1932 N MESA DR UNIT 9
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-1622
Practice Address - Country:US
Practice Address - Phone:707-540-1456
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-01
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ15-1487261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center