Provider Demographics
NPI:1609631399
Name:LAELIA WELLNESS CENTER, LLC.
Entity Type:Organization
Organization Name:LAELIA WELLNESS CENTER, LLC.
Other - Org Name:LAELIA WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAYNA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:928-350-9588
Mailing Address - Street 1:2881 S MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:OR
Mailing Address - Zip Code:97113-7140
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:880 COMMERCIAL ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4108
Practice Address - Country:US
Practice Address - Phone:971-704-5382
Practice Address - Fax:971-385-1725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-21
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty