1437840139 NPI number — ELEVATING WELLNESS LLC

Table of content: (NPI 1437840139)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437840139 NPI number — ELEVATING WELLNESS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELEVATING WELLNESS 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:
6
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:
1437840139
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
33 HILLSIDE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OLD LYME
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06371-1108
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
283 BOSTON POST RD STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EAST LYME
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06333-1571
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-850-5105
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/15/2023

Additional Information

Authorized Official

Authorized Official Last Name:
SEDITA-GATTO
Authorized Official First Name:
JESSICA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
860-850-5105

Provider Taxonomy Codes

  • Taxonomy code: 175F00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 110000333CT02 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: P3645619 . This is a "OXFORD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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