Provider Demographics
NPI:1063268639
Name:WATERLILY WELLNESS, LLC
Entity type:Organization
Organization Name:WATERLILY WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRSCHNER
Authorized Official - Suffix:
Authorized Official - Credentials:LIC AC
Authorized Official - Phone:617-902-8769
Mailing Address - Street 1:0 GOVERNORS AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-3037
Mailing Address - Country:US
Mailing Address - Phone:179-028-7696
Mailing Address - Fax:617-977-9728
Practice Address - Street 1:0 GOVERNORS AVE STE 2
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-3037
Practice Address - Country:US
Practice Address - Phone:179-028-7696
Practice Address - Fax:617-977-9728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-25
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center