Provider Demographics
NPI:1093470221
Name:LONGVIEW WELLNESS CENTER INC
Entity Type:Organization
Organization Name:LONGVIEW WELLNESS CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TERRIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOGAVERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-212-4763
Mailing Address - Street 1:1107 E MARSHALL AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-5602
Mailing Address - Country:US
Mailing Address - Phone:903-758-2610
Mailing Address - Fax:903-758-7081
Practice Address - Street 1:1001 W FAIRMONT ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-3511
Practice Address - Country:US
Practice Address - Phone:903-758-2610
Practice Address - Fax:903-758-7081
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LONGVIEW WELLNESS CENTER INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-11-02
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)