Provider Demographics
NPI:1821521451
Name:PRESTIGE HEALTH & WELLNESS CENTER, PLLC
Entity Type:Organization
Organization Name:PRESTIGE HEALTH & WELLNESS CENTER, PLLC
Other - Org Name:STRONG HEALTH & WELLNESS CENTER, PLLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:FAMILY PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEVON
Authorized Official - Middle Name:M
Authorized Official - Last Name:RAMBERT-HAIRSTON
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:704-910-5982
Mailing Address - Street 1:2711 RANDOLPH RD
Mailing Address - Street 2:SUITE 207
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-2034
Mailing Address - Country:US
Mailing Address - Phone:704-910-5982
Mailing Address - Fax:704-733-9796
Practice Address - Street 1:2711 RANDOLPH RD
Practice Address - Street 2:SUITE 207
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-2034
Practice Address - Country:US
Practice Address - Phone:704-910-5982
Practice Address - Fax:704-733-9796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-10
Last Update Date:2017-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004878261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7005652Medicaid
NC7005652Medicaid