Provider Demographics
NPI:1437814621
Name:SUPREME WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:SUPREME WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:
Authorized Official - Last Name:GARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:704-294-5100
Mailing Address - Street 1:148 E MORGAN ST STE B
Mailing Address - Street 2:
Mailing Address - City:WADESBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28170-2202
Mailing Address - Country:US
Mailing Address - Phone:704-695-0694
Mailing Address - Fax:704-695-0695
Practice Address - Street 1:148 E MORGAN ST STE B
Practice Address - Street 2:
Practice Address - City:WADESBORO
Practice Address - State:NC
Practice Address - Zip Code:28170-2202
Practice Address - Country:US
Practice Address - Phone:704-695-0694
Practice Address - Fax:704-695-0695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-03
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory