Provider Demographics
NPI:1578050605
Name:NEW ROADS WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:NEW ROADS WELLNESS CENTER, LLC
Other - Org Name:NEW ROADS WELLNESS CENTER, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHARMAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-669-4113
Mailing Address - Street 1:29 COUNTRY HILLS RD
Mailing Address - Street 2:
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06514-3217
Mailing Address - Country:US
Mailing Address - Phone:718-669-4113
Mailing Address - Fax:
Practice Address - Street 1:2911 DIXWELL AVE # B10
Practice Address - Street 2:
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3195
Practice Address - Country:US
Practice Address - Phone:203-821-7390
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-14
Last Update Date:2018-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health