1154746410 NPI number — A WELLNESS PLACE LLC

Table of content: (NPI 1154746410)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154746410 NPI number — A WELLNESS PLACE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
A WELLNESS PLACE 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:
1154746410
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
471 SHELBOURNE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PITTSBURGH
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15239-3613
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
412-583-7505
Provider Business Mailing Address Fax Number:
412-342-0402

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8350 FRANKSTOWN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PITTSBURGH
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15221-1336
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
412-583-7505
Provider Business Practice Location Address Fax Number:
412-342-0402
Provider Enumeration Date:
02/24/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GONZALEZ
Authorized Official First Name:
TIMOTHY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
412-583-7505

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  CW16629 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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