Provider Demographics
NPI:1124581103
Name:REFRESH WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:REFRESH WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:972-638-9179
Mailing Address - Street 1:4000 PARKSIDE CENTER BLVD APT 625
Mailing Address - Street 2:
Mailing Address - City:FARMERS BRANCH
Mailing Address - State:TX
Mailing Address - Zip Code:75244-4361
Mailing Address - Country:US
Mailing Address - Phone:972-638-9179
Mailing Address - Fax:
Practice Address - Street 1:4000 PARKSIDE CENTER BLVD APT 625
Practice Address - Street 2:
Practice Address - City:FARMERS BRANCH
Practice Address - State:TX
Practice Address - Zip Code:75244-4361
Practice Address - Country:US
Practice Address - Phone:972-638-9179
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-08
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health