Provider Demographics
NPI:1164221172
Name:COMMUNITY CONNECTIONS WELLNESS CENTER LLC
Entity type:Organization
Organization Name:COMMUNITY CONNECTIONS WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:K
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-907-1719
Mailing Address - Street 1:643 S GREAT SOUTHWEST PKWY STE 102&104
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051-1056
Mailing Address - Country:US
Mailing Address - Phone:602-907-1719
Mailing Address - Fax:
Practice Address - Street 1:643 S GREAT SOUTHWEST PKWY STE 102&104
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-1056
Practice Address - Country:US
Practice Address - Phone:602-907-1719
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-11
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder