Provider Demographics
NPI:1821390287
Name:LAVACA WELLNESS CLINIC, P.A.
Entity Type:Organization
Organization Name:LAVACA WELLNESS CLINIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:479-462-7203
Mailing Address - Street 1:603 S DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:LAVACA
Mailing Address - State:AR
Mailing Address - Zip Code:72941-4129
Mailing Address - Country:US
Mailing Address - Phone:479-674-9181
Mailing Address - Fax:479-674-8105
Practice Address - Street 1:603 S DIVISION ST
Practice Address - Street 2:
Practice Address - City:LAVACA
Practice Address - State:AR
Practice Address - Zip Code:72941-4129
Practice Address - Country:US
Practice Address - Phone:479-674-9181
Practice Address - Fax:479-674-8105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-17
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care