Provider Demographics
NPI:1518630599
Name:AWAKEN WELLNESS NC, LLC
Entity Type:Organization
Organization Name:AWAKEN WELLNESS NC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:TANYA
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBBS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:910-644-0588
Mailing Address - Street 1:5964 DALTON RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-1022
Mailing Address - Country:US
Mailing Address - Phone:910-973-2689
Mailing Address - Fax:725-209-1671
Practice Address - Street 1:2529 RAEFORD RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-5098
Practice Address - Country:US
Practice Address - Phone:910-644-0588
Practice Address - Fax:725-209-1671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-27
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center