Provider Demographics
NPI:1194030403
Name:POLK COUNTY COMMUNITY HEALTH & WELLNESS CENTER, INC.
Entity Type:Organization
Organization Name:POLK COUNTY COMMUNITY HEALTH & WELLNESS CENTER, INC.
Other - Org Name:POLK WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY JO
Authorized Official - Middle Name:
Authorized Official - Last Name:STARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-894-2222
Mailing Address - Street 1:PO BOX 130
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:NC
Mailing Address - Zip Code:28722-0130
Mailing Address - Country:US
Mailing Address - Phone:828-894-2222
Mailing Address - Fax:828-894-2229
Practice Address - Street 1:801 W MILLS ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:NC
Practice Address - Zip Code:28722-8494
Practice Address - Country:US
Practice Address - Phone:828-894-2222
Practice Address - Fax:828-894-2229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-11
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty