1922546746 NPI number — FAMILY WELLNESS AND RECOVERY CENTER, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922546746 NPI number — FAMILY WELLNESS AND RECOVERY CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY WELLNESS AND RECOVERY CENTER, 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:
1922546746
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5121 E. VIRGINIA BEACH BLVD, SUITE C-2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORFOLK
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23502-4041
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-962-9644
Provider Business Mailing Address Fax Number:
757-383-6135

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5121 E. VIRGINIA BEACH BLVD, SUITE C-2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23502-4041
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-962-9644
Provider Business Practice Location Address Fax Number:
757-383-6135
Provider Enumeration Date:
02/01/2017

Additional Information

Authorized Official

Authorized Official Last Name:
POLITE
Authorized Official First Name:
GLORIA
Authorized Official Middle Name:
ROBIN
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
757-962-9644

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  95221 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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