Provider Demographics
NPI:1609643915
Name:ALPHA WELLNESS, LLC
Entity Type:Organization
Organization Name:ALPHA WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON-VALLADE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-519-9388
Mailing Address - Street 1:3851 PENTLAND HILLS DR
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-9242
Mailing Address - Country:US
Mailing Address - Phone:443-519-9388
Mailing Address - Fax:
Practice Address - Street 1:3851 PENTLAND HILLS DR
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-9242
Practice Address - Country:US
Practice Address - Phone:443-519-9388
Practice Address - Fax:
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?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty