Provider Demographics
NPI:1891384061
Name:FREEDOM WELLNESS, LLC
Entity Type:Organization
Organization Name:FREEDOM WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHAVON
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:757-575-8627
Mailing Address - Street 1:5313 MACCHONANCHY ST
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-8114
Mailing Address - Country:US
Mailing Address - Phone:757-575-8627
Mailing Address - Fax:
Practice Address - Street 1:337 EDWIN DR STE 200
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-4560
Practice Address - Country:US
Practice Address - Phone:757-575-8627
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
0Other0