1437531043 NPI number — LIVING ANEW WELLNESS CENTER, PLLC

Table of content: (NPI 1437531043)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437531043 NPI number — LIVING ANEW WELLNESS CENTER, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIVING ANEW WELLNESS CENTER, PLLC
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:
1437531043
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/24/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 42242
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28309-2242
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-578-0232
Provider Business Mailing Address Fax Number:
910-705-8447

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1830 OWEN DR
Provider Second Line Business Practice Location Address:
SUITE 10
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28304-1611
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-745-8712
Provider Business Practice Location Address Fax Number:
910-705-8447
Provider Enumeration Date:
06/19/2015

Additional Information

Authorized Official

Authorized Official Last Name:
DRAKEFORD
Authorized Official First Name:
DAWN
Authorized Official Middle Name:
STATEN
Authorized Official Title or Position:
LICENSED PROFESSIONAL COUNSELOR
Authorized Official Telephone Number:
910-728-5980

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  11591 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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