Provider Demographics
NPI:1508198565
Name:VANNESS ENTERPRISES, LLC
Entity Type:Organization
Organization Name:VANNESS ENTERPRISES, LLC
Other - Org Name:WELLNESS RESTORATION CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RANDEE
Authorized Official - Middle Name:P
Authorized Official - Last Name:VAN NESS
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:719-651-5102
Mailing Address - Street 1:4740 FLINTRIDGE DR STE 101
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-4254
Mailing Address - Country:US
Mailing Address - Phone:719-510-6313
Mailing Address - Fax:719-358-7756
Practice Address - Street 1:4740 FLINTRIDGE DR STE 101
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-4254
Practice Address - Country:US
Practice Address - Phone:719-510-6313
Practice Address - Fax:719-358-7756
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VAN NESS ENTREPRISES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-02-02
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 133NN1002X
CO32854208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty