Provider Demographics
NPI:1609307776
Name:CREATIVE WELLNESS, LLC
Entity Type:Organization
Organization Name:CREATIVE WELLNESS, LLC
Other - Org Name:ADVANCED LASER THERAPY AND WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HARASHA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:314-961-8940
Mailing Address - Street 1:2558 S BRENTWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63144-2309
Mailing Address - Country:US
Mailing Address - Phone:314-961-8940
Mailing Address - Fax:143-961-8969
Practice Address - Street 1:2558 S BRENTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63144-2309
Practice Address - Country:US
Practice Address - Phone:314-961-8940
Practice Address - Fax:314-961-8969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-21
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000165042261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center