1598336133 NPI number — RADIANCE WELLNESS GROUP LLC

Table of content: (NPI 1598336133)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598336133 NPI number — RADIANCE WELLNESS GROUP LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RADIANCE WELLNESS GROUP 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:
Provider Other Organization Name Type Code:
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:
1598336133
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1341 E 3RD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLIAMSPORT
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
17701-5409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-601-4325
Provider Business Mailing Address Fax Number:
570-866-3141

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
953 MARKET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILLIAMSPORT
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
17701-3448
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-601-4325
Provider Business Practice Location Address Fax Number:
570-866-3141
Provider Enumeration Date:
07/06/2021

Additional Information

Authorized Official

Authorized Official Last Name:
PLOCINSKI
Authorized Official First Name:
JAMIE
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
570-601-4325

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1034210900007 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1038257700001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1037997140001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1039567180002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1034210900002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1038257700002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1039455450002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com