Provider Demographics
NPI:1962633446
Name:WAGSTAFF WELNESS CENTER
Entity Type:Organization
Organization Name:WAGSTAFF WELNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:VALARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:REED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-649-0414
Mailing Address - Street 1:1947 ABERGLEN DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-4990
Mailing Address - Country:US
Mailing Address - Phone:704-649-0414
Mailing Address - Fax:
Practice Address - Street 1:1947 ABERGLEN DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-4990
Practice Address - Country:US
Practice Address - Phone:704-649-0414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-02
Last Update Date:2009-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management