Provider Demographics
NPI:1407633597
Name:THE WAVE OF WINNSBORO, LLC
Entity Type:Organization
Organization Name:THE WAVE OF WINNSBORO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:GIULIANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BOARI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-713-4085
Mailing Address - Street 1:28059 US 19 N STE 205
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33761-2620
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1403 GREENBRIER MOSSYDALE RD
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:SC
Practice Address - Zip Code:29180-8932
Practice Address - Country:US
Practice Address - Phone:310-547-7501
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-12
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health