Provider Demographics
NPI:1740766161
Name:COMMUNITY WELLNESS & SUPPORT, LLC
Entity Type:Organization
Organization Name:COMMUNITY WELLNESS & SUPPORT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF SERVICES
Authorized Official - Prefix:MR
Authorized Official - First Name:CLARENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-909-2891
Mailing Address - Street 1:34 MEDICAL PARK BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-9283
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:804-441-9089
Practice Address - Street 1:34 MEDICAL PARK BLVD STE A
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9283
Practice Address - Country:US
Practice Address - Phone:804-909-2891
Practice Address - Fax:804-441-9089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility