Provider Demographics
NPI:1255119780
Name:PRISM CREATIVE ARTS WELLNESS CENTER LLC
Entity type:Organization
Organization Name:PRISM CREATIVE ARTS WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-993-2017
Mailing Address - Street 1:PO BOX 662112
Mailing Address - Street 2:
Mailing Address - City:LIHUE
Mailing Address - State:HI
Mailing Address - Zip Code:96766-7112
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4441 RICE ST UNIT 662112
Practice Address - Street 2:
Practice Address - City:LIHUE
Practice Address - State:HI
Practice Address - Zip Code:96766-7605
Practice Address - Country:US
Practice Address - Phone:720-541-9007
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt TherapistGroup - Multi-Specialty