Provider Demographics
NPI:1346022878
Name:BANYAN WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:BANYAN WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAYNA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:808-633-7132
Mailing Address - Street 1:320 OHUKAI RD STE 414
Mailing Address - Street 2:
Mailing Address - City:KIHEI
Mailing Address - State:HI
Mailing Address - Zip Code:96753-7060
Mailing Address - Country:US
Mailing Address - Phone:808-666-1937
Mailing Address - Fax:
Practice Address - Street 1:320 OHUKAI RD STE 414
Practice Address - Street 2:
Practice Address - City:KIHEI
Practice Address - State:HI
Practice Address - Zip Code:96753-7060
Practice Address - Country:US
Practice Address - Phone:808-666-1937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty