Provider Demographics
NPI:1518746189
Name:WELLDOM LLC
Entity Type:Organization
Organization Name:WELLDOM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:KEISHA
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:704-387-6420
Mailing Address - Street 1:5009 BEATTIES FORD RD STE 107-220
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-2859
Mailing Address - Country:US
Mailing Address - Phone:704-387-6420
Mailing Address - Fax:
Practice Address - Street 1:112 LAKENHEATH LN # A
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-6501
Practice Address - Country:US
Practice Address - Phone:803-840-3312
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service