Provider Demographics
NPI:1073073300
Name:WATERFORD WELLNESS, PA
Entity Type:Organization
Organization Name:WATERFORD WELLNESS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISTIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-376-8118
Mailing Address - Street 1:1003 OLDE WATERFORD WAY STE 1C
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-4168
Mailing Address - Country:US
Mailing Address - Phone:910-376-8118
Mailing Address - Fax:
Practice Address - Street 1:1003 OLDE WATERFORD WAY STE 1C
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-4168
Practice Address - Country:US
Practice Address - Phone:910-376-8118
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-22
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty