Provider Demographics
NPI:1003280157
Name:A PROSPERING VISION HOLISTIC MEDICAL SERVICES, LLC
Entity Type:Organization
Organization Name:A PROSPERING VISION HOLISTIC MEDICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ELIJAH
Authorized Official - Middle Name:
Authorized Official - Last Name:CALDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:203-558-9865
Mailing Address - Street 1:60 N MAIN ST
Mailing Address - Street 2:3RD FLR
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06702-1443
Mailing Address - Country:US
Mailing Address - Phone:203-558-9865
Mailing Address - Fax:
Practice Address - Street 1:60 N MAIN ST
Practice Address - Street 2:3RD FLR
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702-1443
Practice Address - Country:US
Practice Address - Phone:203-558-9865
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:A PROSPERING VISION, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-11-30
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008042640Medicaid