Provider Demographics
NPI:1558048439
Name:PRIME WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:PRIME WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DEO
Authorized Official - Middle Name:
Authorized Official - Last Name:TUMWINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:857-544-6282
Mailing Address - Street 1:16605 N 28TH AVE STE A104
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85053-7551
Mailing Address - Country:US
Mailing Address - Phone:602-607-5151
Mailing Address - Fax:602-607-5206
Practice Address - Street 1:16605 N 28TH AVE STE A104
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85053-7551
Practice Address - Country:US
Practice Address - Phone:602-607-5151
Practice Address - Fax:602-607-5206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-03
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)