Provider Demographics
NPI:1922751353
Name:TEEN MOMS WELLNESS PNCC, LLC
Entity Type:Organization
Organization Name:TEEN MOMS WELLNESS PNCC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DOMINIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:HATCHETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-218-1249
Mailing Address - Street 1:9713 W LISBON AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53222-2533
Mailing Address - Country:US
Mailing Address - Phone:262-218-1249
Mailing Address - Fax:
Practice Address - Street 1:9713 W LISBON AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-2533
Practice Address - Country:US
Practice Address - Phone:414-630-4463
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-26
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management