Provider Demographics
NPI:1699139766
Name:WAVE WOMEN WHO ARE VICTORIOUS OVER EATING, LLC
Entity type:Organization
Organization Name:WAVE WOMEN WHO ARE VICTORIOUS OVER EATING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LAVISTA
Authorized Official - Middle Name:V
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-202-6950
Mailing Address - Street 1:2421 PRESIDENTS DR STE B-21
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36116-1632
Mailing Address - Country:US
Mailing Address - Phone:877-845-7560
Mailing Address - Fax:
Practice Address - Street 1:2421 PRESIDENTS DR STE B-21
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-1632
Practice Address - Country:US
Practice Address - Phone:877-845-7560
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-05
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health