Provider Demographics
NPI:1124865654
Name:WELLNESS GROVE LLC
Entity type:Organization
Organization Name:WELLNESS GROVE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF INFORMATION OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:
Authorized Official - Last Name:SWIGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:330-915-2907
Mailing Address - Street 1:4522 FULTON DR NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2332
Mailing Address - Country:US
Mailing Address - Phone:330-915-2907
Mailing Address - Fax:
Practice Address - Street 1:4522 FULTON DR NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2332
Practice Address - Country:US
Practice Address - Phone:330-915-2907
Practice Address - Fax:330-915-2958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-11
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt TherapistGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0085951Medicaid