Provider Demographics
NPI:1093557381
Name:COLLABORATIVE WELLNESS CENTER LLC
Entity type:Organization
Organization Name:COLLABORATIVE WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:FLATASHA
Authorized Official - Middle Name:ALLEAN
Authorized Official - Last Name:ROLAND
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA, MSNA
Authorized Official - Phone:817-875-8343
Mailing Address - Street 1:2309 BALLANTRAE DR
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-5303
Mailing Address - Country:US
Mailing Address - Phone:817-875-8343
Mailing Address - Fax:
Practice Address - Street 1:1124 GLADE RD STE 120
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-4292
Practice Address - Country:US
Practice Address - Phone:817-875-8343
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-06-10
Last Update Date:2025-05-15
Deactivation Date:2024-08-09
Deactivation Code:
Reactivation Date:2024-09-11
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No163W00000XNursing Service ProvidersRegistered Nurse
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center