Provider Demographics
NPI:1215646039
Name:CENTER STATE WELLNESS LLC
Entity type:Organization
Organization Name:CENTER STATE WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APRN
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:HOWARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-556-7101
Mailing Address - Street 1:60 COMMERCIAL ST STE 303
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-5096
Mailing Address - Country:US
Mailing Address - Phone:603-556-7101
Mailing Address - Fax:949-404-6458
Practice Address - Street 1:60 COMMERCIAL ST STE 303
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-5096
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:2022-11-21
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty