Provider Demographics
NPI:1043412711
Name:21ST CENTURY TOTAL WELLNESS, LLC
Entity Type:Organization
Organization Name:21ST CENTURY TOTAL WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RESIDENT AGENT
Authorized Official - Prefix:MR
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:PRATER
Authorized Official - Suffix:
Authorized Official - Credentials:COTA
Authorized Official - Phone:219-756-4695
Mailing Address - Street 1:5522 E 989 N
Mailing Address - Street 2:
Mailing Address - City:DEMOTTE
Mailing Address - State:IN
Mailing Address - Zip Code:46310-8016
Mailing Address - Country:US
Mailing Address - Phone:219-345-3892
Mailing Address - Fax:
Practice Address - Street 1:5522 E 989 N
Practice Address - Street 2:
Practice Address - City:DEMOTTE
Practice Address - State:IN
Practice Address - Zip Code:46310-8016
Practice Address - Country:US
Practice Address - Phone:219-345-3892
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty