Provider Demographics
NPI:1609643071
Name:NOVEL MIND AND WELLNESS CENTER
Entity Type:Organization
Organization Name:NOVEL MIND AND WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND OPERATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLE
Authorized Official - Middle Name:MELVIN
Authorized Official - Last Name:LOGAN
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:850-597-9732
Mailing Address - Street 1:1804 MICCOSUKEE COMMONS DR STE 210
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5471
Mailing Address - Country:US
Mailing Address - Phone:850-597-9732
Mailing Address - Fax:
Practice Address - Street 1:1804 MICCOSUKEE COMMONS DR STE 210
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5471
Practice Address - Country:US
Practice Address - Phone:850-597-9732
Practice Address - Fax:850-999-7591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-06
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center