Provider Demographics
NPI:1043402464
Name:CLEVLAND WELLNESS CENTER
Entity Type:Organization
Organization Name:CLEVLAND WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:HUGHES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-853-0173
Mailing Address - Street 1:2488 LOCHSTONE DRIVE
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-5186
Mailing Address - Country:US
Mailing Address - Phone:704-853-0173
Mailing Address - Fax:704-853-0535
Practice Address - Street 1:1054 COLLEGE AVENUE
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28080
Practice Address - Country:US
Practice Address - Phone:704-853-0173
Practice Address - Fax:704-853-0535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-10
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891036YMedicaid
NC891036YMedicaid