Provider Demographics
NPI:1386267797
Name:BEACON WELLNESS CENTER LLC
Entity type:Organization
Organization Name:BEACON WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CAMERON
Authorized Official - Middle Name:DUPREE
Authorized Official - Last Name:TROTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-375-5937
Mailing Address - Street 1:21258 E RITTENHOUSE RD STE 104
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-9340
Mailing Address - Country:US
Mailing Address - Phone:480-306-4127
Mailing Address - Fax:
Practice Address - Street 1:21258 E RITTENHOUSE RD STE 104
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-9340
Practice Address - Country:US
Practice Address - Phone:480-306-4127
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-20
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health