Provider Demographics
NPI:1407607336
Name:PRISM WELLNESS CENTER PLLC
Entity type:Organization
Organization Name:PRISM WELLNESS CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NP
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLIER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:610-772-3325
Mailing Address - Street 1:14175 W INDIAN SCHOOL RD # SETB4195
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-8407
Mailing Address - Country:US
Mailing Address - Phone:610-772-3325
Mailing Address - Fax:866-398-8310
Practice Address - Street 1:9299 W OLIVE AVE STE 604
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85345-8386
Practice Address - Country:US
Practice Address - Phone:610-772-3325
Practice Address - Fax:866-398-8310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-28
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty