1104869981 NPI number — THE WELLNESS CORNER, LLC

Table of content: (NPI 1104869981)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104869981 NPI number — THE WELLNESS CORNER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE WELLNESS CORNER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
TWC COMPOUNDING SPECIALIST
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104869981
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/19/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17733 OLD JEFFERSON HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRAIRIEVILLE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70769-3934
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-677-8200
Provider Business Mailing Address Fax Number:
225-677-8201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17733 OLD JEFFERSON HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRAIRIEVILLE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70769-3934
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-677-8200
Provider Business Practice Location Address Fax Number:
225-677-8201
Provider Enumeration Date:
06/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HUFF
Authorized Official First Name:
ANGIE
Authorized Official Middle Name:
Authorized Official Title or Position:
PIC / OWNER
Authorized Official Telephone Number:
225-677-8200

Provider Taxonomy Codes

  • Taxonomy code: 333600000X , with the licence number:  PH31188 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 054.020608 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 29094 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: NRP.022798750-03 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PHY.006397-IR , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: LA2351 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: PHNR.FO.60798674 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 64002439A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 2041-43 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 12670 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 6121 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 0214002006 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 114624 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336C0004X , with the licence number: PHNR000397 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336H0001X , with the licence number: 4881 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2035271 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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