Provider Demographics
NPI:1871029595
Name:CORNUCOPIA WELLNESS GROUP, LLC
Entity Type:Organization
Organization Name:CORNUCOPIA WELLNESS GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:GARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:LCAS
Authorized Official - Phone:919-808-5540
Mailing Address - Street 1:115 E HARDEN ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:GRAHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27253-3001
Mailing Address - Country:US
Mailing Address - Phone:919-808-5540
Mailing Address - Fax:
Practice Address - Street 1:115 E HARDEN ST
Practice Address - Street 2:SUITE 105
Practice Address - City:GRAHAM
Practice Address - State:NC
Practice Address - Zip Code:27253-3001
Practice Address - Country:US
Practice Address - Phone:919-808-5540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-02
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management