Provider Demographics
NPI:1013401124
Name:EVERNORTH DIRECT HEALTH LLC
Entity Type:Organization
Organization Name:EVERNORTH DIRECT HEALTH LLC
Other - Org Name:JOHNSTON WELLNESS CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:FINANCIAL ANALYSIS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:COOLIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-277-1170
Mailing Address - Street 1:25500 N NORTERRA DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85085-8200
Mailing Address - Country:US
Mailing Address - Phone:623-277-1170
Mailing Address - Fax:
Practice Address - Street 1:735 GREENVILLE AVE
Practice Address - Street 2:BLDG D
Practice Address - City:JOHNSTON
Practice Address - State:RI
Practice Address - Zip Code:02919
Practice Address - Country:US
Practice Address - Phone:623-277-1170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-21
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center