Provider Demographics
NPI:1982292249
Name:KTR WELLNESS, LLC
Entity type:Organization
Organization Name:KTR WELLNESS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEANA
Authorized Official - Middle Name:
Authorized Official - Last Name:CALLAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:RDN
Authorized Official - Phone:201-500-7296
Mailing Address - Street 1:688 SEAGULL DR
Mailing Address - Street 2:
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-4944
Mailing Address - Country:US
Mailing Address - Phone:201-960-9636
Mailing Address - Fax:201-608-7111
Practice Address - Street 1:140 E RIDGEWOOD AVE STE 415
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-3915
Practice Address - Country:US
Practice Address - Phone:201-720-1900
Practice Address - Fax:201-367-3779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-04
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1811461650OtherDEANA CALLAHAM, RDN