Provider Demographics
NPI:1093514200
Name:ADVANCE WELLNESS GROUP LLC
Entity type:Organization
Organization Name:ADVANCE WELLNESS GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:EBONY
Authorized Official - Middle Name:S
Authorized Official - Last Name:HAGENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-665-9134
Mailing Address - Street 1:7915 OLIVE BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63130-2020
Mailing Address - Country:US
Mailing Address - Phone:314-665-9134
Mailing Address - Fax:314-453-3897
Practice Address - Street 1:7915 OLIVE BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63130-2020
Practice Address - Country:US
Practice Address - Phone:314-665-9134
Practice Address - Fax:314-453-3897
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-10
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No251E00000XAgenciesHome Health
No253J00000XAgenciesFoster Care Agency
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
No385H00000XRespite Care FacilityRespite Care
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child