Provider Demographics
NPI:1902348964
Name:ENLIVEN MBS, LLC
Entity Type:Organization
Organization Name:ENLIVEN MBS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NATUROPATHIC MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:VANESSA JANE
Authorized Official - Middle Name:FONTANILLA
Authorized Official - Last Name:RUIZ
Authorized Official - Suffix:
Authorized Official - Credentials:NMD
Authorized Official - Phone:347-470-9766
Mailing Address - Street 1:2108 S RURAL RD
Mailing Address - Street 2:#24
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-1420
Mailing Address - Country:US
Mailing Address - Phone:347-470-9766
Mailing Address - Fax:
Practice Address - Street 1:11000 N SCOTTSDALE RD
Practice Address - Street 2:STE 230
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-6130
Practice Address - Country:US
Practice Address - Phone:347-470-9766
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-08
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ161567175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175F00000XOther Service ProvidersNaturopathGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1194274639Medicaid