Provider Demographics
NPI:1710408448
Name:ULTIMATE WELLNESS PROVIDERS CO
Entity Type:Organization
Organization Name:ULTIMATE WELLNESS PROVIDERS CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LASONJA
Authorized Official - Middle Name:
Authorized Official - Last Name:MALONE
Authorized Official - Suffix:
Authorized Official - Credentials:CCMA
Authorized Official - Phone:832-705-5360
Mailing Address - Street 1:3203 KELLING ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77045-4346
Mailing Address - Country:US
Mailing Address - Phone:832-705-5360
Mailing Address - Fax:
Practice Address - Street 1:3203 KELLING STREET
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77045
Practice Address - Country:US
Practice Address - Phone:832-705-5360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1366970394Medicaid