1750429148 NPI number — AGAPE' WELLNESS CENTER & WOUND CARE, LLC

Table of content: (NPI 1750429148)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750429148 NPI number — AGAPE' WELLNESS CENTER & WOUND CARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AGAPE' WELLNESS CENTER & WOUND CARE, 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:
1750429148
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P. O. BOX 9281 RTE # 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KINGSHILL
Provider Business Mailing Address State Name:
VI
Provider Business Mailing Address Postal Code:
00851
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
340-778-0688
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PLOT 6 CLIFTON HILL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGSHILL
Provider Business Practice Location Address State Name:
VI
Provider Business Practice Location Address Postal Code:
00851
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
340-778-0688
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WATTY
Authorized Official First Name:
HUBERT
Authorized Official Middle Name:
H
Authorized Official Title or Position:
OWNER / MANAGER
Authorized Official Telephone Number:
918-869-3466

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  23898 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200046880B , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 700522158 . This is a "MEDICARE B" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 200046880A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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