Provider Demographics
NPI:1356158885
Name:BE WISE WELLNESS CLINIC LLC
Entity type:Organization
Organization Name:BE WISE WELLNESS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:CAUDELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-486-4328
Mailing Address - Street 1:PO BOX 464
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85380-0464
Mailing Address - Country:US
Mailing Address - Phone:480-664-4641
Mailing Address - Fax:800-793-4656
Practice Address - Street 1:5830 N 19TH AVE BLDG B
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-2494
Practice Address - Country:US
Practice Address - Phone:800-817-6437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-17
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health