Provider Demographics
NPI:1407633902
Name:RADIANCE HEALTH & WELLNESS CLINIC LLC
Entity Type:Organization
Organization Name:RADIANCE HEALTH & WELLNESS CLINIC LLC
Other - Org Name:RADIANCE HEALTH & WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DR EZEOGU
Authorized Official - Prefix:
Authorized Official - First Name:AMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FABAH
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:816-510-4549
Mailing Address - Street 1:12641 ANTIOCH RD # 1053
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66213-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6225 RAYTOWN TRFY
Practice Address - Street 2:
Practice Address - City:RAYTOWN
Practice Address - State:MO
Practice Address - Zip Code:64133-3846
Practice Address - Country:US
Practice Address - Phone:816-510-4549
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-11
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care