Provider Demographics
NPI:1235863531
Name:PROGRESSIVE LIVING WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:PROGRESSIVE LIVING WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LYDDIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GETAWERU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-773-8480
Mailing Address - Street 1:2177 E WARNER RD STE 101
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-3511
Mailing Address - Country:US
Mailing Address - Phone:480-773-8480
Mailing Address - Fax:480-546-3626
Practice Address - Street 1:2177 E WARNER RD STE 101
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85284-3511
Practice Address - Country:US
Practice Address - Phone:480-773-8480
Practice Address - Fax:480-546-3626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZBH7784Medicaid