Provider Demographics
NPI:1568249480
Name:GREAT WAVE WELLNESS, LLC
Entity Type:Organization
Organization Name:GREAT WAVE WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEN
Authorized Official - Middle Name:
Authorized Official - Last Name:CERRETO
Authorized Official - Suffix:
Authorized Official - Credentials:LAC
Authorized Official - Phone:508-314-1156
Mailing Address - Street 1:198 LITTLETON RD STE 202
Mailing Address - Street 2:
Mailing Address - City:WESTFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01886-3429
Mailing Address - Country:US
Mailing Address - Phone:508-314-1156
Mailing Address - Fax:
Practice Address - Street 1:198 LITTLETON RD STE 202
Practice Address - Street 2:
Practice Address - City:WESTFORD
Practice Address - State:MA
Practice Address - Zip Code:01886-3429
Practice Address - Country:US
Practice Address - Phone:508-314-1156
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-13
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty