Provider Demographics
NPI:1689235319
Name:CENTER STATE WELLNESS LLC
Entity type:Organization
Organization Name:CENTER STATE WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:MR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:603-556-7101
Mailing Address - Street 1:102 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-3863
Mailing Address - Country:US
Mailing Address - Phone:603-556-7101
Mailing Address - Fax:949-404-6458
Practice Address - Street 1:102 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-3863
Practice Address - Country:US
Practice Address - Phone:603-556-7101
Practice Address - Fax:949-404-6458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty