Provider Demographics
NPI:1316603285
Name:360 WELLNESS & NUTRITION, PA
Entity Type:Organization
Organization Name:360 WELLNESS & NUTRITION, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:RENU
Authorized Official - Middle Name:
Authorized Official - Last Name:KASULA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-852-3450
Mailing Address - Street 1:1704 S GLENDALE AVENUE
Mailing Address - Street 2:SUITE A
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-4678
Mailing Address - Country:US
Mailing Address - Phone:252-237-1225
Mailing Address - Fax:
Practice Address - Street 1:1704 GLENDALE DR SW
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-4678
Practice Address - Country:US
Practice Address - Phone:252-237-1225
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-15
Last Update Date:2023-04-13
Deactivation Date:2023-04-04
Deactivation Code:
Reactivation Date:2023-04-13
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty