Provider Demographics
NPI:1760099360
Name:TAG VIRTUAL WELLNESS LLC
Entity Type:Organization
Organization Name:TAG VIRTUAL WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:GIRARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-293-9978
Mailing Address - Street 1:PO BOX 2387
Mailing Address - Street 2:
Mailing Address - City:SEABROOK
Mailing Address - State:NH
Mailing Address - Zip Code:03874-2387
Mailing Address - Country:US
Mailing Address - Phone:617-293-9978
Mailing Address - Fax:
Practice Address - Street 1:168 WALTON RD UNIT 19
Practice Address - Street 2:
Practice Address - City:SEABROOK
Practice Address - State:NH
Practice Address - Zip Code:03874-4529
Practice Address - Country:US
Practice Address - Phone:617-293-9978
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-28
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty